Piergiorgio Bolasco Definitions according to regional regulations - - PowerPoint PPT Presentation

Piergiorgio Bolasco

Current and future structure and

• rganization in the

assistance of renal patients in chronic haemodialysis

Definitions according to regional regulations (resolution 25/29 dated 1st July 2010)

The Dialysis Reference Centre is an intensive support centre, belonging to an Operational Nephrology Unit equipped with in-patient beds. The centre is in charge of providing assistance to clinically unstable and high-comorbidity patients and emergency patients. The Territorial Assistance Dialysis Centre (CAD) is a specialized structure the aim of which is to guarantee dialysis treatment to clinically unstable patients thanks to the continuous presence of a nephrologist throughout the dialysis session. This type of assistance is reserved to patients devoid of intensive or sub-intensive critical characteristics. The Territorial Careful Assistance Dialysis Centre (CAL) is a specialized structure aimed at guaranteeing dialysis treatment to patients judged as being clinically stable by nephrologist. The opening and support of this type

• f centre is characterized by the offer of an easily accessible localized

service not requiring the presence of a nephrologist during treatment, and lower costs.

Current situation in the Province of Cagliari

• ne Reference Centre for Nephrology Dialysis and Transplant in a

Hospital with high hospitalization rates - G. Brotzu Hospital

• ne Reference Centre for Dialysis Emergencies and Assistance

to patients in chronic dialysis, also providing specialist care for contagious patients (HBV+ and HIV+) ASL Cagliari

• ne Territorial Structure made up of 5 centres for dialysis: one

coordination CAD, one hospital CAD, one hospital CAL, 2 community CALs ASL Cagliari

Local distribution of Public Centres for Local distribution of Public Centres for Nephrology and Dialysis Nephrology and Dialysis

Province of Cagliari Province of Cagliari

Obstacles to the application of virtuous organization models

The only centre with in-patient beds (the increasing demand results in an

• verload of the structure for patients referring to the centre) is the Brotzu

Hospital (managed by a different authority to the ASL in Cagliari). Critical lack of renal beds in the ASL of Cagliari capable of lightening the load

• f the Brotzu Hospital Reference Centre.

In the area covered by the ASL of Cagliari renal patients are only accepted in two suburban hospitals, usually on General Medical Wards. The territory is affected by numerous geographical issues and poor road

• access. The two suburban centres are located 60 and 75 Km from Cagliari.

There is no political-administrative impetus to formalize the relationships and procedures between the two HS centres. High incidence of new dialysis patients controlled by the three private dialysis centers that already provide assistance to over 200 patients.

The figures in the public structures The figures in the public structures The figures in the public structures

Brotzu Hospital: 110 haemodialysis patients, 47 receiving peritoneal dialysis, 6 hemodialysis emergency beds, 26 beds for residential renal and 10 transplant patients, 2 D.H. places, >750 transplant patients followed up periodically + biopsies & vascular access activities, 13 operational outpatients clinics. ASL Cagliari: total 240 haemodialysis patients in 6 centres, 0 beds for residential renal patients, vascular access activity,14

• perational outpatients

clinics in the territory (Cagliari & surroundings).

The modus operandi we adhere to in the lack

• f formal regulations:

a brotherhood policy Hub: Hub:

• Brotzu

Brotzu

• SS. Trinit
• SS. Trinità

à

spokes spokes

Muravera Muravera Quartu Quartu Sant Sant

• Elena

Elena Isili Isili Sarroch Sarroch Monastir Monastir Others in Others in progress progress

To what extent do sick people still feel protected in hospital?

• In Hospital the individual

feels better taken care of than anywhere else

• He expects his/her illness to

be cured

• Life in the outside

environment is better

• Hospital infections are a

serious problem

• Patients no longer enjoy

their stays in hospital

• Alternative medical care

facilities have developing

Hospital Territory integration

Integration

Programmatic integration: a fundamental aspect for the definition of strategic choices and priorities, in relation to the awareness of territorial requirements, from the services provided to the resources available within each health area; Institutional integration: which requires the establishing of collaborations between different institutions (ASL, local authorities etc.) arranged with a view to achieving mutual objectives for global health, extended also to the life of a person in his/her community; Managerial integration: in the organizational and operative choices between the different operative structures: unitary within health area throughout the different services comprised; Professional integration: strictly linked to the adoption of company profiles and guidelines aimed at steering inter-professional work towards the production of home, semi-residential and residential health services

The solution is to avoid conflicts of The solution is to avoid conflicts of authority and provide a reciprocal authority and provide a reciprocal guarantee of maximum availability in guarantee of maximum availability in accepting patients for treatment accepting patients for treatment whenever staff and resources allow whenever staff and resources allow

H  requests that the territory solve the problems it cannot control unaided

Integration: focus on the sector

The territory dumps the problems it cannot control on the hospital  T Integration: global focus

The assistance programme is

• rganized and managed in a

synergistic manner

Together but how?

By defining scheduled methodological procedures and assistance to be applied in both a routine and emergency situation. By requesting that Institutions unify the functional government in

• rder to create an

integrated functional network By attempting to unify the organization of services By implementing comparable technological acquisitions common to both the Hospitals and the territory based on clinical involvement and patients needs By developing integrated economic programmes: unity determines a positive impact on the acquisition of goods

Types of instruments for integration

Functional programmes conceived for specific pathologies with admission of patients with particular problems to HUB hospitals; Functional programmes according to the type of patient: stable or not heavy unstable: allocation of the patient to the territory nearest their place of residence; The critical patient should temporarily or momentarily stay in the HUB hospital; The territory should be provided with patient transportation facilities for use under routine and emergency conditions; ideal target: integrated hospital-territory departments?

The results we would expect

More effective assistance; Rationalization of organization; Focus the attention of the Health Services on the PATIENT; Cost-effectiveness and rationalization of expenditure;

Elements to be implemented -a

Guarantee application of the Essential Assistance Limits (LEA) for all citizens, irrespective of their health care facility; Improvement through homogeneous procedures of hospital and territorial

• utpatients

clinics with a strong focus on prevention aimed at slowing down the race to dialysis. Creation of highly specialized nephrology clinics: e.g. nutrition, doppler ultrasonography, study of vascular access, treatment of CKD-MBD etc.

Elements to be implemented- b

Establish a productive and collaborative dialogue with General Phisicians (including their active participation in the definition of Hospital-territory assistance programmes); Avoid self-referencing: promoting exchanges of teams capable of undertaking control audits, either internal or managed by external agencies. Protected shared tele-network accessible to both parties (e.g. access to updated medical charts in Hospital and

• n the Territory)

Cultural delay of the territory Cultural delay of the territory Cultural delay of the territory

H T integration is linked to:

New culture throughout the territory medical: medical: focused on socio focused on socio-

• sanitary

sanitary programmes for chronic programmes for chronic conditions conditions

• rganizational/managerial
• rganizational/managerial focused
• n activities developed in healthcare

centres, to be integrated IN THE LACK OF A NEW CULTURE FOR THE TERRITORY

⇓

TERRITORIAL HOSPITALIZATION WILL PREVAIL

advantages advantages

These models would enhance a homogenization of procedures An allocation method would be developed, becoming almost automatic and natural for nephrologists and patients, who would be assigned to a Reference Centre

• r a CAD on the basis of clinical severity.
• CALs

CALs would be destined to would be destined to

• extinction

extinction

• : justifications

: justifications associated to the reduced availability of financial associated to the reduced availability of financial resources are no longer acceptable: resources are no longer acceptable: a patient at risk a patient at risk should no longer be should no longer be

• left alone

left alone

• .

.

Combine politics with actual assistance!!!

• minimum requirements should be defined with the

minimum requirements should be defined with the legislator by expert nephrologists as: legislator by expert nephrologists as:

• The patient

s SAFETY takes priority over all other issues: legislators or Doctors who do not : legislators or Doctors who do not

• take into

take into account account

• the problems encountered by renal patients

the problems encountered by renal patients frequently overlook this, which should likewise invariably frequently overlook this, which should likewise invariably be determined in medical and legal terms; be determined in medical and legal terms;

• the perception of a patient

s safety does not derive solely from financial availability (in acquiring operators and technology) but also from a detailed knowledge of local territorial situations.

Conclusions Conclusions -

• a

a

No models or declarations are needed for a successful synergy between Hospitals and the Territory All it takes is a dose of good will The project doesn t refers to a long-term time frame The role of the professionals is therefore strategic The territory has room for growth in terms of

• rganizational culture

Improve information exchange systems between H and T and General Practitioners: from admission to discharge and beyond Local Authorities and Municipalities should be involved: they should not be allowed to shirk their share of assistance to Citizens Regional and National politics must officially formalize a Hospital-Territorial model

Summing up

The renal patient should travel freely from the Hospital (where he has lived his acute moments) to the Territory (as a chronic patient, where he knows he will receive the same type of care he received in the hospital but close to home) in the smoothest possible way......... this is true continuity in healthcare!