Editing Palliative care

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= Palliative care =

Palliative care is a group of complex medical conditions due to complex needs and care requirements, as it requires the integration of different services due to the multiple and complex needs of people in palliative care. People in palliative care most often have complex, chronic, or multiple health problems that, depending on the condition and stage of the disease, require medical monitoring and intervention. Palliative care does not only include addressing the medical needs of patients, but also social and psychological needs and help with daily living activities (dressing, feeding, going to the toilet, buying groceries, etc.). For this reason, care coordination is important to ensure that all aspects of a person’s health are balanced and met, especially the patient’s healthcare needs.

Healthcare professionals at all levels of healthcare have a key role in managing and coordinating all necessary health services, as well as risks. Regular healthcare helps prevent and manage potential complications arising from existing health problems. Regular monitoring can prevent deterioration and reduce the risk of hospitalization. Rehabilitation services such as physical therapy, occupational therapy, are often needed by people in palliative care to maintain or improve their level of functionality and quality of life. Healthcare professionals oversee these therapies to ensure they are effective and appropriate for the individual’s condition.

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== 1. Contribution to the health system ==

For people with life-threatening conditions such as those in palliative care, the healthcare system must and should focus not only on stabilizing the medical condition but also on alleviating symptoms, pain and stress of serious illness and providing support to family members. In addition to the above, participants at the primary health care level actively participate in the coordination and organization of the provision of services in the user’s home. The health status of people in palliative care can change significantly over a shorter or longer period. The integration of healthcare ensures that services are adapted to these changes, whether they require more intensive medical care or adjustments to the care plan. In short, the integration of healthcare into long-term care services provides comprehensive, continuous and coordinated care that meets the multiple needs of individuals, improving their quality of life and health outcomes with a positive organizational and financial impact on the health system.

Healthcare participates in the provision of palliative care according to the stage of progression of the patient’s illness through three forms. The first form is the provision of healthcare to people with disabilities or chronic illnesses where there are no significant changes. Such persons require specific or enhanced healthcare. The second group includes people who have developed a serious illness with a certain progression and change in needs. The third group consists of people who have social problems or difficulties related to activities of daily living, and their healthcare is specific because it cannot be provided in the usual way or place. Therefore, the degree of progression of the health condition is closely related to social factors, which ultimately affect the final outcome of care.

Through the working models it applies, the Health Promotion Center aims to raise awareness among counseling users, as well as the wider community, about the importance of a healthy lifestyle in promoting health and preventing and controlling not only obesity but also other chronic diseases and conditions. It strives to increase users’ knowledge of the principles of proper nutrition and health-oriented physical activity, as well as knowledge of risk factors for heart and vascular diseases, as well as for diabetes, cancer, etc. Through the different types of support it provides, it strives to motivate people with unhealthy lifestyles to make positive changes. The counseling center applies an individual approach and group counseling. Thus, there is the possibility of individual counseling with a doctor, nutritionist and psychologist, performing anthropometric measurements with an analysis of body composition on a medical scale and creating a diet plan and menu. The counseling center is open on Mondays, Tuesdays, Wednesdays and Fridays from 7 a.m. to 3 p.m., and on Thursdays from 7 a.m. to 8 p.m. The services are free of charge and a referral from a chosen doctor is not required. Interested parties can make an appointment by phone, e-mail or by coming to the premises of the Institute’s Department of Public Health and Health Promotion.

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=== 1.1. General and specific needs for medical interventions and health services ===

Different groups of users need different types of medical interventions and health services. Based on the previous classification into three groups according to the progression of the patient’s illness, we can define the framework of necessary services adapted to functional abilities, i.e. the person’s capabilities. The first group includes immobile or poorly mobile persons who, depending on the stage of disease progression, depend on medical technologies or aids, such as oxygen therapy, hemodialysis, or regular interventions to maintain their current condition. The second group consists of people who have partially recovered from acute exacerbations, but are on the path of further exacerbations (acute and chronic). These are people after a stroke, people with neurological diseases or people with the progression of malignant diseases, i.e. patients in palliative care, where it is necessary to continuously adapt healthcare to changing needs. The third group consists of people who have problems with performing daily activities independently (e.g. self-care, normal social functioning), such as people with intellectual disabilities, very old and frail people, etc. Healthcare for them must first and foremost be adapted to these specific circumstances.

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== 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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== 3. Impatient capacities for providing palliative care and nurses ==

Palliative care can be provided in healthcare institutions such as inpatient wards of health centers, hospital wards for extended care and palliative care, and specialized palliative care institutions such as hospices or specialized hospitals for extended care. In addition, in addition to healthcare institutions, care is also provided in social care institutions such as foster families or inpatient homes for the elderly. In addition to institutional forms of care, depending on the possibilities and support of the patient’s family, care can be organized at the patient’s home with the support of services operating in the community, such as volunteers.

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=== 3.1. Inpatient capacities organized by hospital institutions ===

Healthcare for long-term care patients is provided in all forms of hospital treatment. The system recognizes complex patients and those in long-term care from emergency hospital admissions, through acute hospital wards and day hospitals, to extended care wards, i.e. long-term care and palliative care. The organization of individual services and accommodation capacities differs between regions, most often reflecting the specificity of available resources and the level of development of integrated or palliative care. Complex patients and those in long-term care are most often identified at emergency admissions in acute care hospitals. Later, during hospital treatment, problems often arise due to the length of the patient’s stay in the hospital, and more and more hospitals are introducing the role of nurse coordinators for palliative care and complex patients, who have a special role in care coordination and discharge planning. patients who need long-term care. Due to various forms of hospital mergers and ownership transfers, some general hospitals have day hospitals, acute beds, extended care beds and palliative care beds.

Special hospitals usually have beds for extended care, long-term care and palliative care. Also, especially for patients who have mental problems, care is provided in special psychiatric hospitals. Given that some patients who needed long-term care also needed long-term care, a special hybrid model was introduced in some institutions where hospitals used the right (within their capabilities!) to form special units, which in fact they represent social care wards where people are accommodated. who have no family or the possibility of independent living. (Ugljan Special Hospital, Lopača Special Hospital, …)

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=== 3.2. Inpatient capacities organized by health centers ===

Outpatient clinics are organized in certain places and branches of health centers. This service enables the temporary accommodation of patients who need enhanced care, and there are no adequate accommodation capacities in social institutions and hospitals in the region. Thus, small departments have been organized in certain places and branches of health centers where patients with serious health problems and the need for care that cannot be provided at home are taken care of. In some situations, these units are specifically focused on palliative care and are fully equipped for palliative care, such as the case of the Split-Dalmatia County Health Center located in the city of Split.