Editing Palliative care (section)

== 2. Health professions involved in providing palliative care by levels of healthcare ==

Professions involved in the provision of palliative care are categorized according to two levels of care provision: general palliative care and specialist palliative care. General palliative care encompasses a wide range of health and non-health services and services involved in the care of palliative patients, but also other groups of patients, including health professionals, psychologists, social workers, clergy and volunteers and associations. Providers of general palliative care have basic knowledge of palliative care in order to timely

recognize a palliative patient and eliminate the basic symptoms of the disease.

Within the health system at the primary health care level, the general family medicine team (family medicine doctor and nurse), visiting nurse (visiting nurse) and home health care that may include a nurse and physiotherapist participate in the provision of general palliative care. . In addition to the aforementioned participants, emergency medical services operate at the primary health care level, which also participate in the care of palliative patients for emergency needs.

On the other hand, specialist palliative care brings together teams of health professionals, psychologists and social workers dedicated exclusively to palliative care. In addition, it includes volunteers and civil society organizations that have specific knowledge and experience in the field of caring for palliative patients. Experts of the specialized palliative team solve complex situations and symptoms, and volunteers contribute to the quality of palliative care at the patient’s home with the aim of empowering patients and family members and continuing to provide care at home.

At the primary primary health care level, a palliative care coordinator and a mobile palliative team consisting of a doctor and nurses participate in the provision of specialized palliative care.

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=== 2.1. Professions participating at the primary health care level Family Physicians as Coordinators of General Care ===

Family physicians play a key role in coordinating care between different specialists and health services. For patients who need long-term care, this coordination is crucial to ensure that all aspects of the patient’s health are addressed in a cohesive manner, avoiding unnecessary duplication of services, and ensuring that the most effective treatment plans are followed. In the Croatian health system, family medicine doctors are often gatekeepers to specialized medical services. They assess the need for specialist consultations and refer patients, ensuring that patients receive specialist care when needed, while preventing unnecessary burden on specialist segments of the health system.

'''Palliative Care Coordinator'''

For the needs of palliative care, palliative care coordinators have a key role in coordinating care at the primary health care level in the Republic of Croatia. Through the Center for Palliative Care Coordination at the level of the Health Center, the palliative care coordinator connects all stakeholders important for the development and provision of palliative care in the county, from stakeholders in the health system, social welfare to the support of civil society. and units of local self-government. For the needs of providing health care and care at home for patients, a mobile palliative team is included, and if necessary, other home services such as home health care. The coordinators not only coordinate professionals within the health system, but also involve volunteers and civil society organizations in the provision of care.

In addition, they provide support to family members through education, counseling and information about available support options in the community. The palliative care coordinator has a comprehensive insight into the condition and resources available in the area where they work, as well as the needs of the patients they care for. They have a particularly important role in planning the discharge of patients from the hospital who need long-term care, which will continue to be provided at the user’s home or in a certain institution. Their goal is to include the patient in palliative care in a timely manner and organize the necessary services for the continuation of care.

'''Mobile Palliative Care Team'''

The palliative care model in the Republic of Croatia is designed as an integrated system in which all participants involved in the provision of palliative care are networked. However, in addition to the palliative care coordinator, mobile palliative care teams operating within the Health Center have a prominent role. The mobile palliative care team consists of a doctor and a nurse, and their task is to provide specific medical care and interventions to palliative patients through home visits or outpatient work. This primarily includes pain therapies, other symptomatic treatments or any other interventions that can be performed at home or at the primary level in order to reduce the burden and unnecessary effort on the part of the palliative patient.

'''Patronage Activities'''

Outpatient services in the community include various preventive interventions that are carried out at home, and are aimed at chronic patients, complex patients (including those who require long-term therapy), pregnant women and mothers with infants. They are organized by health centers, and are carried out by nurses in cooperation with general practitioners. Patronage nurses are primarily registered nurses trained to make home visits for a population standard of 5,100 inhabitants per patronage nurse. Most health visits relate to chronic patients in order to provide instructions and demonstrations of individual procedures for self-monitoring and prevention of complications of basic chronic diseases, as well as for the administration of therapy to bedridden and bedridden patients. , in agreement with his chosen doctor.

'''Home Healthcare'''

Home care services are provided by institutions registered and authorized for home care as the primary level of health care. The home care institution provides nursing care and rehabilitation of patients, and can also provide physical therapy at home. A home care facility may choose to provide temporary hospital care to patients in need of nursing care and rehabilitation.

'''Centers for Integrated Care and Counseling'''

Since the health system reform in 2021, the emphasis has been placed on care integration and strengthening community care. In this regard, amendments and additions to the Health Protection Act have been made, which provide for the development of special counseling centers for chronic patients and complex cases. The purpose of these counseling centers is to provide a single point where complex patients and their caregivers can receive comprehensive information, as well as the care they need to ensure quality long-term care at home and in the community. Nurses will take on the role of coordinators of these counseling centers and centers for complex patients, i.e. support for long-term care. This model was designed based on the positive experiences of palliative care coordinators, but also some other counseling centers that are already operating successfully. Among them, the pharmacy counseling center operating at the Center Zagreb Health Center should be highlighted.

'''Emergency Medical Services'''

Although they do not have a direct role, emergency medical services, out-of-hospital and hospital, are very important as part of the coordination of palliative care. Good cooperation between the participants specialized in providing palliative care and emergency medical services is important for mutual benefit. Fast and correct emergency interventions enable the resolution of health problems at the earliest stage, prevention of complications and keeping patients at home or in the institution where they live. On the other hand, good coordination prevents unnecessary use of emergency services, overloading of outpatient systems, especially hospital systems and hospital departments for patients who need long-term care.

The best example of cooperation with the emergency service is precisely palliative care, where a joint manual or guidelines for the care of palliative patients has been published. (National guidelines for the work of out-of-hospital and hospital emergency medical services with patients requiring palliative care. Available at https://www.hzhm.hr/smjernice/ ).

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=== 2.2. Professions participating at the secondary healthcare level ===

At the secondary healthcare level, especially in the context of palliative care, the practice of coordinating and providing care between hospitals and hospital systems varies considerably. An example of good practice in the care of palliative patients is KBC Rijeka, which has become a pioneer in the integration of care for palliative patients. KBC Rijeka founded the Department of Integrated and Palliative Care as a valuable resource that promotes interdisciplinarity, intersectoral cooperation and, in general, cooperation with outpatient stakeholders in health and social care in the field of care for palliative patients.

Hospital palliative care teams, made up of a physician and one or more nurses, have been established in some hospitals. These teams represent newly established organizational units whose primary purpose is to ensure the smooth transition of patients from the hospital environment to home or community care. They achieve this by planning the discharge of patients from the hospital in a way that ensures continuity of care and timely information to stakeholders at the primary health care level. Also, these teams provide support and education to family members to ensure that the patient receives the necessary care and support after discharge from the hospital. At the level of the Republic of Croatia, these teams have been implemented in several hospitals, such as the Clinical Hospital Center Zagreb, which shows a trend of comprehensive integration of palliative care into the national health system.

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