Implementing Outcome Measures Within an Enhanced Palliative Care Day Care Model

Exploring the 'citizen organization': an evaluation of a regional Australian community-based palliative care service model

Background

Little Haven is a rural, community-based specialist palliative care service in Gympie, Australia. Its goals are to provide highest quality of care, support and education for those experiencing or anticipating serious illness and loss. Families and communities work alongside clinical services, with community engagement influencing compassionate care and support of dying people, their families and communities. Public Health Palliative Care promotes community engagement by community-based palliative care services and is grounded in equal partnerships between civic life, community members, patients and carers, and service providers. This takes many forms, including what we have termed the 'citizen organization'.

Objectives

This paper reports on an evaluation of Little Haven's model of care and explores the organization's place as a 'citizen' of the community it services.

Design

A co-designed evaluation approach utilizing mixed-method design is used.

Methods

Multiple data sources obtained a broad perspective of the model of care including primary qualitative data from current patients, current carers, staff, volunteers and organizational stakeholders (interviews and focus groups); and secondary quantitative survey data from bereaved carers. Thematic analysis and descriptive statistics were generated.

Results

This model of care demonstrates common service elements including early access to holistic, patient/family-centred, specialized palliative care at little or no cost to users, with strong community engagement. These elements enable high-quality care for patients and carers who describe the support as 'over and above', enabling good quality of life and care at home. Staff and volunteers perceive the built-in flexibility of the model as critical to its outcomes; the interface between the service and the community is similarly stressed as a key service element. Organizational stakeholders observed the model as a product of local activism and accountability to the community.

Conclusion

All participant groups agree the service model enables the delivery of excellent care. The construction of a community palliative care service as a citizen organization emerged as a new concept.

Consensus-based recommendations for the development and expansion of palliative day care clinics in Germany: results of a Delphi study

BACKGROUND

Needs-based, patient-oriented palliative care includes palliative day care clinics as a specialized semi-inpatient care offer. However, the establishment and development of these facilities has been unsystematic. Research is needed to strengthen their transparency and ensure their accessibility, quality, and structural adequacy. A national Delphi study was conducted to generate appropriate recommendations for the establishment and development of palliative day care clinics in Germany.

METHODS

Recommendations were formulated from focus group data on the development and expansion of palliative day care clinics in Germany. Experts on in- and outpatient palliative care rated 28 recommendations for relevance and feasibility, respectively, using a 4-point Likert-type scale. Suggestions for improvement were captured via free text comments. Items were considered consented when more than 80% of the experts scored them 4 (strongly agree) or 3 (somewhat agree), regarding both relevance and feasibility.

RESULTS

A total of 23 experts (32% response rate) completed three Delphi rounds. Following the first round, 10 of 28 recommendations were revised according to participants' comments; 1 recommendation was rejected. After the second round, 3 of these 10 recommendations were revised, while 3 were rejected. Consensus was achieved after the third round for 22 of the initial recommendations.

CONCLUSIONS

The Delphi-consented recommendations provide a basis for the targeted evidence- and needs-based development of palliative day care clinics. The findings show a need for standards setting and the meaningful integration of these clinics into existing structures.

TRIAL REGISTRATION

The present study was prospectively registered on April 20, 2020, with the German Clinical Trials Register (DRKS00021446).

[Empirically derived recommendations for the development and expansion of day hospices in Germany - Results of a Delphi expert panel]

INTRODUCTION

A needs-based and patient-oriented hospice and palliative care also includes day hospices as a specialised semi-inpatient care offer. The establishment and development of these facilities in Germany has been rather unsystematic. In order to ensure quality and adequacy of these structures, research is needed.

METHODS

A Delphi consensus study was conducted online from November 2022 to February 2023 aiming at generating recommendations for the development and expansion of day hospices in Germany. For each recommendation, the participants indicated on a four-point verbal rating scale how much they agreed upon a) the relevance and b) the feasibility of the recommendation. Items were considered consented when 80% of the participants (strongly) agreed with the recommendation regarding both criteria. If no consensus was reached, the recommendations were revised according to the participants' free text comments and presented in the next Delphi round. Descriptive analyses were applied.

RESULTS

A total of 64 experts participated in the first Delphi round and 44 in the second. In round 1, 34 recommendations and in round 2 six recommendations were consented. The final set contains a total of 40 recommendations: 18 on the tasks of day hospices, 13 on cooperation, 7 on funding, and 2 on public relations.

DISCUSSION

Recommendations for the development and expansion of day hospices in Germany were developed. Due to their highly rated feasibility, the recommendations should be directly transferable into care practice. It remains to be seen to what extent they will be taken into account in the renegotiation of the framework agreement for day hospices.

CONCLUSION

The Delphi-consented recommendations provide a basis to guide action in the currently very dynamic development of hospice work and palliative care in Germany.

Benefits of Early Palliative Care Integration in a Day Care Program: The Patients' Perspective

Aim: The aim of this study is to present the experiences of cancer patients who participate in a social model palliative day care program (PDCP). This is the first research study that evaluates early integration of PDCP, from the patients' perspective, in Central and Eastern Europe. Methods: A descriptive qualitative study using five focus groups was conducted with patients cared by Hospice Casa Sperantei Foundation (HCS) in Brasov, Romania. Fifty participants were recruited from the PDCP. Discussions were transcribed and analyzed thematically. Results: Three major categories emerged from the focus groups: (1) significance of diagnosis before integration of palliative care (PC); (2) perceptions of diagnosis after integration of PC; and (3) benefits of attending the PDCP. The findings indicate that PDCPs facilitate continuity of care for patients and families with PC needs by addressing and responding to physical, psychosocial, and spiritual needs. Participation in the PDCP fosters a sense of connectedness with others, helps individuals reconnect with self, and provides an opportunity to engage in activities that bring meaning and value to daily living. Conclusions: This study is highly important in the context of a national- and regional-wide interest for increasing the coverage of PC needs of patients and families, by varying the types of services. It explores the benefits of integration of PC services early on the trajectory of the disease of cancer patients. The themes that emerged from this study are consistent with previous international studies referring to benefits of early integration of PC throughout PDCP. Future research is needed to examine further the benefits of early integration of PDCP services for patients living with serious illnesses. Clinical Trials Registration Number 1/03.02.2020.

Live Well, Die Well: The Development of an Online, Arts-Based Palliative Care Programme in the Shadow of the COVID-19 Pandemic

The Covid-19 crisis led to an increase in the 'total pain' of many terminally ill patients who faced a reduction in support, due to the temporary closure of front-line palliative day therapy services. A hospice volunteer, I instigated an online day therapy programme for patients previously attending face-to-face day therapy. Participant feedback revealed the importance of providing a space for ongoing peer support for participants' changing sense of identity, an issue for time-limited day therapy programmes. An exploration of key concepts associated with palliative care established the multiple connections between such changing identity and arts-based approaches to living well. This article charts how I used this understanding to develop an alternative, online arts-based support programme, Live well, die well. It explores the links between ongoing mutual support, arts-based activity and the reactions to a shifting identity in patients with a life-limiting illness.

The added value of palliative day care centres: A full-population cross-sectional survey among clients and their family caregivers in Flanders, Belgium

In addition to palliative care delivery at home or in hospital, palliative day care centres occupy an in-between position in palliative care. In palliative day care centres, multidisciplinary teams provide holistic care and support for people with (chronic) life-limiting conditions, or clients, in a homely surrounding, allowing them to remain living at home while attending a specialist palliative care service. This study aims to evaluate palliative day care centres from a user perspective. We conducted a full-population cross-sectional survey of clients (N = 86) and their family caregivers (N = 63) in all five palliative day care centres in Flanders, Belgium from January until December 2019. We used validated instruments supplemented with self-developed items to measure participants' reasons for use, support provided, unmet support needs and added value to other (palliative) care services across palliative care domains, i.e., physical, psychological, social and spiritual care. Response rate was 77% for clients and 81% for family caregivers. The most often indicated reasons for use were that the client needs social contacts (clients: 73%, caregivers: 65%), to enable the client to live at home as long as possible (resp. 58%, 55%) and to reduce the family caregiver's mental burden (resp. 42%, 65%). Three out of four family caregivers felt better able to combine daily activities with caring for the client (77%) and felt better able to perform their family care-giving tasks (77%) because the client attends the palliative day care centre. Thirty-six per cent of clients had received support for social needs exclusively in the palliative day care centre and not from any professionals outside palliative day care. Palliative day care centres seem to be of added value for those care domains to which often less attention is paid in other settings, particularly social and emotional support, both for clients and family caregivers.

Status, demand and practice models of palliative day-care clinics and day hospices: a scoping review

BACKGROUND

Little is known about the structure, accessibility, service provision and needs of palliative and hospice day-care in Germany and abroad. Researchers, healthcare providers and policy makers would benefit from a systematic overview.

AIM

The aim was to identify, describe and summarise available evidence on status, demand and practice models of palliative day-care clinics and day hospices. A secondary aim was to disclose research gaps and present recommendations for clinical practice and future research.

DESIGN

The scoping review followed the methodological framework of Arksey and O'Malley. The analysed publications included studies of varying kinds to describe the current state of the art.

DATA SOURCES

Using a highly sensitive search strategy, the authors searched PubMed, Web of Science Core Collection, CINAHL and Google Scholar within the publication window of inception to 12 June 2020. An additional hand search of the reference lists of the identified review articles was conducted.

RESULTS

The authors screened the titles and abstracts of 2643 studies, retrieved 197 full texts and included 32 articles in the review. The review identified nine major themes: (1) the referral process, (2) models of care, (3) patient characteristics, (4) demand, (5) the discharge process, (6) perceptions of services, (7) funding and costs, (8) outcome measurement and (9) education.

CONCLUSIONS

There is a need for further research to identify groups of patients who would receive the most benefit from palliative and hospice day-care and to determine any necessary revisions in admission criteria.

Status quo palliativmedizinischer Tageskliniken und Tageshospize in Deutschland: Ergebnisse einer gemischt-methodischen Studie

Ziel der Studie Der Bestand von Tageshospizen und palliativmedizinischen Tageskliniken in Deutschland soll erstmals systematisch erhoben und analysiert werden.

Methodik In dieser gemischt-methodischen Studie wurden Einrichtungsleitungen in leitfadengestützten Interviews (06.–07.2020) und standardisierter Fragebogenerhebung (08.–10.2020) zu einrichtungsbezogenen Kriterien befragt. Interviewdaten wurden qualitativ inhaltsanalytisch, quantitative Daten deskriptiv ausgewertet.

Ergebnisse Die Interviews (n = 7) liefern einen Überblick über Organisation und Versorgungsangebot hospizlich-palliativer Tageseinrichtungen. Von 28 standardisiert befragten Einrichtungen waren 13 bereits in Betrieb. Die zumeist an andere Versorger angebundenen Einrichtungen bieten in der Regel zwischen 2 und 8 Tagesplätze an.

Schlussfolgerung Aufgrund der gezeigten Entstehungsdynamik scheint eine systematische Integration der neuen Strukturen in die bestehende Hospiz- und Palliativversorgung sinnvoll.

Reporting standards, outcomes and costs of quality improvement studies in Ireland: a scoping review

OBJECTIVES

To profile the aims and characteristics of quality improvement (QI) initiatives conducted in Ireland, to review the quality of their reporting and to assess outcomes and costs.

DESIGN

Scoping review.

DATA SOURCES

Systematic searches were conducted in PubMed, Web of Science, Embase, Google Scholar, Lenus and rian.ie. Two researchers independently screened abstracts (n=379) and separately reviewed 43 studies identified for inclusion using a 70-item critique tool. The tool was based on the Quality Improvement Minimum Quality Criteria Set (QI-MQCS), an appraisal instrument for QI intervention publications, and health economics reporting criteria. After reaching consensus, the final dataset was analysed using descriptive statistics. To support interpretations, findings were presented at a national stakeholder workshop.

ELIGIBILITY CRITERIA

QI studies implemented and evaluated in Ireland and published between January 2015 and April 2020.

RESULTS

The 43 studies represented various QI interventions. Most studies were peer-reviewed publications (n=37), conducted in hospitals (n=38). Studies mainly aimed to improve the 'effectiveness' (65%), 'efficiency' (53%), 'timeliness' (47%) and 'safety' (44%) of care. Fewer aimed to improve 'patient-centredness' (30%), 'value for money' (23%) or 'staff well-being' (9%). No study aimed to increase 'equity'. Seventy per cent of studies described 14 of 16 QI-MQCS dimensions. Least often studies reported the 'penetration/reach' of an initiative and only 35% reported health outcomes. While 53% of studies expressed awareness of costs, only eight provided at least one quantifiable figure for costs or savings. No studies assessed the cost-effectiveness of the QI.

CONCLUSION

Irish QI studies included in our review demonstrate varied aims and high reporting standards. Strategies are needed to support greater stimulation and dissemination of QI beyond the hospital sector and awareness of equity issues as QI work. Systematic measurement and reporting of costs and outcomes can be facilitated by integrating principles of health economics in QI education and guidelines.

Exploring the status of and demand for palliative day-care clinics and day hospices in Germany: a protocol for a mixed-methods study

Background

To date, the establishment and development of palliative day-care clinics and day hospices in Germany have been completely unsystematic. Research is needed to gain insight into these services and to ensure their accessibility and quality. Accordingly, the ABPATITE research project aims at: (1) identifying the characteristics of palliative day-care clinics and day hospices in Germany, (2) determining demand and preferences for these services, and (3) proposing recommendations (with expert agreement) for the needs-based establishment and development of these services.

Methods

The research is a multi-perspective, prospective, observational study following a mixed-methods approach across three study phases. In phase 1a, qualitative expert interviews will be conducted to capture the facility-related characteristics of palliative day-care clinics and day hospices in Germany; the results will feed into a questionnaire sent to all such institutions identified nationwide. In phase 1b, a questionnaire will be sent to local statutory health insurance providers, to gain insight into their contracts and accounting and remuneration models. In phase 2a, a service preference survey will be conducted with patients and family caregivers. In phase 2b, semi-structured interviews with management staff will explore the factors that promote and hinder the provision of service. In phase 2c, the external perspective will be surveyed via focus groups with local actors involved in hospice and palliative care. In phase 3a, focus groups with representatives from relevant areas will be conducted to develop recommendations. Finally, in phase 3b, recommendations will be agreed upon through a Delphi survey.

Discussion

The empirically developed recommendations should enable the establishment and development of day hospices and palliative day-care clinics in Germany to be better managed, more oriented to actual demand, and more effectively integrated into wider health care services. Importantly, the findings are expected to optimize the overall development of hospice and palliative care services.

Trial registration:

The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00021446; date of registration: April 20, 2020). The study is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number.

Association between attendance at a specialist palliative care day unit and improvement in patient symptoms and quality of life

BACKGROUND

Specialist palliative day care is an area of palliative care which has a notable scarcity of research. Evidence is needed on the role of palliative day care to improve patients' quality of life and symptom management, while recognising the different patient cohorts that use the service.

AIM

To determine the symptoms and quality of life of the patient cohort that are affected by the completion of a full therapeutic cycle (8 to 9 weeks) at a specialist palliative care day unit (SPCDU).

METHOD

A retrospective cohort study was carried out from January 2016 to December 2017. Patient related outcome measures (PROMs) were collected as part of routine clinical paperwork at admission and discharge, and these were used to determine symptoms and quality of life pre-attendance and on completion of an 8 to 9 week therapeutic cycle at the SPCDU.

RESULTS

Descriptive analysis demonstrated improvement across the many symptoms that were analysed. Quality of life analysis also established improvement. Statistically significant difference was achieved in several areas. Total physical symptoms (p value=.009) confirmed the positive impact attendance at SPCDU has on physical symptoms. Specific symptoms which displayed a statistically significant difference included: poor appetite (p value=.002), weakness (p value=.03) and the anxiety felt by family/friends (p value=.029). The quality of a patient's life also displayed statistically significant difference (p value=.000).

CONCLUSION

This study demonstrates that attendance at a SPCDU may positively impact a patients' symptoms and quality of life. A more uniform national approach to specialist palliative day care delivery, alongside multi-setting research, may further bolster the image of palliative day care. This will improve referrals to and occupancy of SPDCUs and benefit the palliative patient in the community.

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

Effectiveness of palliative care interventions offering social support to people with life-limiting illness-A systematic review

Individuals managing the challenges of life-limiting illness require adequate social support to maintain quality of life. Qualitative research reports that patients value highly the social support obtained in palliative care interventions such as day care and group therapies. This systematic review aims to summarise existing quantitative evidence on palliative care interventions that facilitate social support. Research literature was systematically searched using electronic databases and key journals. Searches returned a total of 6,247 unique titles of which sixteen were eligible for inclusion. Interventions include group therapies, group practical interventions and palliative day care. Outcome measures and study designs were heterogeneous. Only one study used a validated outcome measure of social support. Benefits were influenced by participant characteristics such as baseline distress. Partial economic evaluation was attempted by two studies. Methodological challenges include attrition and use of outcome measures that were insensitive to change. Statistically significant results were reported in psychological and physical domains. Evidence is limited due to methodological issues and a scarcity of quantitative research, particularly regarding long-term benefits and cost-effectiveness. Interventions may be more beneficial to some groups than others.