Transcript Document

Paletti (’Palette’in English) Strengthening of the know-how and
development of structures in palliative and
terminal care as an expert collaboration
within the province of North Karelia
1.4.2013-31.3.2015
“The patient has a right to good
symptom management in
palliative and terminal care
regardless where they live”
Ministery of Social Affairs and Health (STM) publication 2010:6
Backround and need for project
Need for this project became from many international, national and local
recommendations
•WHO prediction
• Geriatrics and palliative care will become two of the most important medical
specialities in a future
•National recommendations (names of these recommendations have been translated in
English – they can be found from STM website only by their Finnish names)
• Good palliative care in Finland. STM publication 2010:6
• Development of cancer care during 2010-2020. STM statemant 2010:6
• Making patient’s journey more fluent in palliative care. STM statement 75/2009
• Fair treatment recommendations; Symptom management of dying patient.
Duodecim and Association of Palliatiive Medicine 2008
• Education is root to customer-centred and multi-professional services. STM 2012:7
•Provincal recommendations
• Provincal welfare program 2015. North Karelia Regional Council 2009
• Strategies of social- and health services in different municipalities, e.g. Joensuu
and Lieksa
•Previous projects
• Developmant of palliative care 2005-2008 in North Karelia province
• Homecare24 – 2008-2011 in North Karelia province
Starting point at North Karelia province,
spring 2013
Patient’s journey within palliative and terminal care has been built in
heterogeneous and unfair way within different areas of the province
• Overall structure, operators and areas of responsibility are missing (only
some of this is present)
Organization of palliative and terminal care is inadequate
• Organizing the coordination of local terminal care
• Multi-professional networks (doctor/nurse working team, social workers,
physiotherapists)
• Palliative care nurse network exists – but the way it works is not planned or
goal-orientated
• Expert consultation practices of acute and difficult to manage symptoms
during the evening-, night- and weekend (e.g. pain management)
Know-how of palliative and terminal care varies
• Aging population of the province/different illnesses becoming more common
and chronic, increases the need for basic- and specialist knowledge in all
health care organizations.
• There are shortcomings within know-how (different levels of
basic/specialized care, educational responsibility has not been defined)
• There are no skilled hospice-type hospital wards or units within the province
Organisations taking part into this project
• Karelia University of Applied Sciences (Karelia-amk)
• Management of the project
• North Karelia Health and Social Services Consortium (PKSSK)
• North Karelia Municipal Education and Training Consortium (PKKY)
Project goals:
1. Uniform structure and approach at teaching of palliative and terminal care in Karelia
AMK and PKKY will strengthen the quality and effectiveness of care, and increase the
cooperation and appropriate division of work in educational organisations and hospitals.
2. Province has network of experts within palliative and terminal care. All health centres
have named doctor-nurse working pair who are responsible for implementing and
developing care. Palliative and terminal care is possible to carry out at home or local
health centre by using the expertise of multiprofessional team. Prearranged consultation
support is available from specialized hospitals or local health centres. Electronic
communication systems and IT applications are used in consultations and meetings.
3. North Karelia’s local nursing care structure and management systems of palliative and
terminal care enable expert collaboration, high-quality, effective and health economically
sustainable use of holistic palliative care ladder. Municipalities and workplaces have
holistic and patient-centred way of working, they use agreed approaches and take into
account supporting of family members and loved-ones. When treatment of difficult
illness is well planned and organised, it is also humanly good and economically
sustainable.
PALETTI – Strengthening of the know-how and
development of structures in palliative and terminal care as
an expert collaboration within the province of North Karelia
Field
of
palliative
care
KARELIA
Development-,
education- & research
cooperation
Structures
•Portals
•Action plans
PKSSK
Responsibilities
•Organizing palliative
care
•Education planning &
implementation
Expert cooperation &
consultation support Palliative and terminal
care at home, local
health centres and
nursing homes
PKKY
Cooperation
•Multiprofessio
Registered nurses
nal networks
•Development palliative care network
work
2008 and symptom
control guidelines
5 municipalities, 4 nursing
homes, PKSSK, N-K cancer
association, Karelia AMK.
Uniform
approach model
for basic- &
continuing
education
Palliative project
2005-2008
Provincal palliative and terminal care
model
Organisation
•Palliative care
•Development
cooperation
Development & education
cooperation
Discharge practises and
Plan for home-based
terminal care
Homecare24-project
2008-2011
Nurse/ doctor
working pair and
multiprofessional
network action
plan and
consultation
practices
8 municipalities, 10 nursing homes, Fire &
rescue service, 3 associations, PKSSK,
Karelia AMK
Chart 1. 120213, H. Myller
Paletti – project; actions
PKSSK
KARELIA
•Creating basic- and continuing
education model for health care
staff and students and producing
novel, interactive and process
conventional service activities
(KARELIA, PKKY, PKSSK)
•Clarifying multiprofessional
network and creating novel network
approach (the principle of
knowledge community,
management of skill needs)
•Implementation of local terminal
care plan
•Visualisation of patient’s terminal
care journey (portals)
•Creating provincal ’around the
clock’ (24/7) consultation system
(e.g. pain) (joint emergency unit,
Mediatri-computer program,
multi-channel communication
system in place)
•Up-to-date guidelines
•Role of fire and rescue-staff in
implementation of home based
palliative and terminal care
PKKY
•Strengthening of the know-how
of teaching staff
•Strengthening of the know-how
of students, (young
people/adults) pilot (PKKY,
Karelia)
•Surveying the development
needs for teaching and learning
•Visualization and modelling of
good terminal care environment
Expert cooperation on wards, homes, and
nursing & residential homes
Students’ shared study courses, practice and
Thesis-works
Chart 2.
100613 H.Myller
PALETTI 2013-2015
ORGANISATIONCHART
PROVINCE OF NORTH KARELIA
Karelia-amk
Project manager
Planner
Project expert
Coordinating
nurse
Doctor
PKSSK
Collaboration
forum
STEERING GROUP
Project expert
Planner
PKKY
Patient-lead palliative and terminal care on wards,
homes, nursing and residential homes
Chart 3. 100613,H.Myller
Project results
Provincal palliative and terminal care operating entity
1.Uniform basic study course for palliative and terminal care (KareliaAMK, PKKY)
2.Continuing education model to strengthen know-how in Palliative and
terminal care; PKKY, Karelia-AMK, PKSSK
3.Description of good terminal care environment and visual modeling
(PKSSK:n portals, PKKY ja Karelia AMK)
4.Provincal, multi-professional palliative and terminal care network
approach
5.Terminal care pathway-portals within PKSSK internet system
6.Clarification of the possibility for ambulance services to support and
implement terminal care at home outside of city centres
Paletti-project in practice
Project doctor-nurse pair of each muncipality and multi-professional network:
•Work from the beginning of the project, put results into practise and inform colleagues about them
•Are responsible for mapping out the development needs of palliative and terminal care in a future and
will keep staff of their organisations well informed about new practises.
PKSSK coordinating nurse and doctor
•Coordinate provincal activities, maintain the portals, inform about new practises within PKSSK intraand extranet, and use new technologies to communicate and pass information
PKKY and Karelia AMK students
•Take project development work into different work places during their practical studies and following
their graduation, later on will participate into further education
PKKY and Karelia AMK teachers
•Inform about new education courses on provincal and national level
•Collect further education and development needs from multi-professional network
•Are responsible for basic- and further education of palliative and terminal care and developing further
education programs
Project staff (PKKY; PKSSK; KARELIA)
•Bringing the project development progress and results into expert discussions, informing the desicionmakers about them
•Informing about the project internally within the organisations and outside of them
•Articles about development work and good practises into professional magazines, producing and
distributing publications
•Presenting project work and results in national and potentially international training sessions,
conferences and benchmarking-trips
Paletti-project contacts
Henna Myller
Project manager
Karelia-amk
+358 50 348 7548
[email protected]
Minna Peake
Registered nurse
PKSSK
+358 50 381 7963
[email protected]
Katja Väyrynen
Project expert
PKKY
+358 50 562 4685
[email protected]
Satu Hyytiäinen
Project planner
Karelia-amk
+358 50 315 6573
[email protected]
Leena Surakka
Medical doctor
PKSSK
+358 50 443 1553
[email protected]
Riitta Piitulainen
Project planner
PKKY
+358 50 577 7860
[email protected]
Address: Tikkarinne 9
80200 Joensuu, Finland
Website: www.karelia.fi/paletti