Role and perspectives of informal care: a qualitative study of informal caregivers in the Republic of Croatia.

OBJECTIVES: Population ageing and the prevalence of multimorbidity represent major challenges for healthcare systems. People who need long-term care have complex conditions requiring both health and social services. Informal caregivers are emerging as an important part of the long-term care ecosystem. This paper aims to explore the position and capacities of informal caregivers in Croatia. DESIGN: Health and social care legislative documents were analysed using a structured set of keywords. In addition, focus groups were conducted with informal caregivers who cared for a family member. The qualitative method of thematic analysis was used. SETTING AND PARTICIPANTS: Two focus groups were conducted with 15 caregivers (13 women and 2 men). Geographically, participants came from all four NUTS2 Croatian regions. All participants cared for a close family member. The length of care provision ranged from 3 to 35 years. Focus groups were conducted using the Zoom platform. RESULTS: The analysis of the documents indicates the fragmentation of national policy into health and social policy. Long-term care as a term is recognised only in health policy. However, some components related to long-term care are part of social policy. Caregivers are recognised in social policy, although not in healthcare. In focus groups, three main themes were identified as follows: (1) position and role of the caregivers in the system and society; (2) types of care based on the recipient's need and (3) support for the caregivers. CONCLUSION: The research showed that the process of exercising certain rights and services for caregivers is not sufficiently clear and feasible in practice. There is a lack of a clearly defined role of caregivers and relationships towards professional care providers in the system. The key to improving long-term care is connecting community services, including health and social services, both formal and informal, with the process of providing care.

Relationships between Physical Activity and Selected Chronic Diseases among Functionally Independent Long-Term Care Residents during the Post-Lockdown Period in Croatia.

The aim of this observational study was to investigate the level and association of physical activity and selected chronic diseases in functionally independent LTC residents after prolonged physical and social isolation during COVID-19 in Croatia. Adhering to the inclusion criteria, 180 functionally independent residents were included in the study. Assessment of physical activity was carried out by 7-day motor monitoring. Prolonged physical and social isolation negatively affected the achieved level of physical activity of LTC residents (x¯ = 5058.74). Major depressive disorder resulted in significantly lower residents' physical activity scores, demonstrating a shrinking effect ranging from 0.42 to 0.45. A significant negative impact on the residents' physical activity was also found in the presence of osteoarthritis and iron deficiency anemia, where a downward effect was present in the range from 0.66-0.72 and 0.64 to 0.66. The presence of comorbidities has a significant negative impact on the residents' physical activity, where a downward effect is present in the range from 0.91-0.92.

Nurse coordinator of care as a facilitator of integration processes in palliative care.

AIMS AND OBJECTIVES: This paper investigates the feasibility and the perception of the nurse's role as the palliative care coordinator. BACKGROUND: Integrated care is a global imperative in all healthcare improvement processes. Due to Andrija Stampar's success in the organisation of public health services, Croatia today has more than hundred years of experience in care integration. The palliative care system has been continuously developing since 2014 as an integrated care model, with nurses as care coordinators. METHODS: The study used a mixed methodology based on pragmatic research principles, including an analysis of strategic and policy documents and reports, and thematic analysis of focus group conducted with palliative care coordinators, following COREQ checklist. RESULTS: Although a legal, professional and financial regulation of nurse coordinators has been achieved, a number of implementation challenges remain. These challenges arise as a result of long-term fragmentation of the health and social care, and can be found in both horizontal and vertical integration of care, that is in the dimensions of functional, clinical, cultural and social integration. CONCLUSIONS: Nurses play a central role in care coordination. Coordination and integration promote professionalisation with clear roles and tasks. However, even with the legal, professional and financial implementation of the nurse coordinator model, it has to be further promoted as an equally important job in the healthcare system, with nurses as competent professionals in charge of care coordination. RELEVANCE TO CLINICAL PRACTICE: Palliative care provides a range of individualised, coordinated services that meet the medical and non-medical needs of seriously ill patients. Described model of palliative care in Croatia is particularly important because it was developed as an integrated part of health care (and partly social welfare) system, indicating with the nurse's role as palliative care coordinator that coordination is a continuous process that requires a dedicated professional role.

A Qualitative Study on the Position and Role of Volunteers in Integrated Care-An Example of Palliative Care in Croatia.

Volunteers have been present in palliative care since its inception. With the development of palliative care systems, their role and position are changing. Given growing long-term care needs and limited resources in health and social care, volunteers are becoming an important resource in meeting these needs. In Croatia, palliative care has been developing as an integrated care model since 2014. To assess the position and the role of volunteers, we analyzed legislative documents from healthcare and social care and conducted a focus group with volunteers in palliative care. We found that volunteers provide support from the social aspect of care, for the patient and the family. The formal palliative care system involves them as partners in the provision of care, even though this cooperation is informal. The main determinants of their activities are an individualized approach, flexibility, a community presence, and project funding. In conclusion, these determinants allow them to react quickly to identified needs, but with them come some uncertainties of their sustainability. Their activities could indicate what needs to be integrated between health and social care and in what areas. Volunteers both fill in gaps in the system and are ahead of the system, and by doing this they develop new processes around identified unmet needs.

Integration processes within the Croatian palliative care model in 2014 - 2020.

In Croatia, palliative care has been developing as an integral part of the health care system since 2014. This development is in line with the integrated care concept emerging in many countries. However, there are a number of implementation problems. The aim of this article was to identify positive and negative determinants for the integration of palliative care in Croatia. We identified policy processes or organizational changes within three key domains: the development of new organizational structures, stakeholders' empowerment, and removing barriers to the provision of integrated palliative care. The progress visible in these domains shows the sustainability of the palliative care model used in Croatia. However, there are also barriers hindering the integration of palliative care. We conclude that patient-centred and process-based change in health care can have a positive effect on the integration of care. Staff education and regulation of business processes are key for the sustainability of reforms. Lastly, it seems easier to achieve the integration of care when it develops as a bottom-up model and reflects the need for new processes, than when it is imposed from above as a single regional or national model.

Croatia: Health System Review.

This analysis of the Croatian health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Croatia has a mandatory social health insurance system with nearly universal population coverage and a generous benefits package. Although per capita spending is low when compared to other EU countries, the share of public spending as a proportion of current health expenditure is high and out-of-pocket payments are low. There are sufficient physical and human resources overall, but some more remote areas, such as the islands off the Adriatic coast and rural areas in central and eastern Croatia, face shortages. While the Croatian health system provides a high degree of financial protection, more can be achieved in terms of improving health outcomes. Several mortality rates are among the highest in the EU, including mortality from cancer, preventable causes (including lung cancer, alcohol-related causes and road traffic deaths) and air pollution. Quality monitoring systems are underdeveloped, but available indicators on quality of care suggest much scope for improvement. Another challenge is waiting times, which were already long in the years before 2020 and are bound to have increased as a result of the COVID-19 pandemic.

Origins and effects of the 2014-2016 national strategy for palliative care in Croatia.

Croatia is among the last countries in Europe to develop organized palliative care at the national level. Real changes in this area started after the parliamentary elections in 2011 and culminated in the 2013 adoption of the Strategic Plan for Palliative Care Development 2014-2016. The National Board for Palliative Care (NBPC), appointed by the Ministry of Health, was in charge of creating a scalable palliative care model and national guidelines. The Board drew on experiences from both neighbouring countries with similar societies and/or health care models (Bosnia and Herzegovina, Poland) and an international leader in palliative care (United Kingdom). It recognised that provision of palliative care in Croatia, thus far based on volunteering and isolated enthusiastic activities, needed to be improved through professionalization, regulation, and organized development. A variety of policy measures was used to implement these changes, including the introduction of professional guidelines and new payment models. The development of new palliative care structures and services significantly increased the number of patients who could access palliative care, from around 1-2% of patients needing such care in 2011 to 20-35% in 2014. It also ensured the provision of more appropriate services at each point of the palliative care pathway. The Strategy was extended for the 2017-2020 period.

Dacryocystitis provoked by recurrence of extramedullary plasmacytoma of the orbit: a case report.

Extramedullary plasmacytoma (EMP) of the orbit is an extremely rare tumor, which frequently manifests with nonspecific symptoms. In the case reported, the symptoms of relapsing dacryocystitis appeared before the diagnosis of orbital EMP in a 60-year-old man. Moreover, EMP of the right submandibular gland that had been excised and treated by radiotherapy preceded the orbital lesion by seven years. The present report emphasizes the importance of an extensive medical workup to rule out multiple myeloma or other malignant lymphoproliferative diseases, because their treatment and prognosis are very different. Additionally, it is necessary to consider all tumors that can provoke relapsing dacryocystits.

Melanocyte as a possible key cell in the pathogenesis of psoriasis vulgaris.

Current research in pathogenesis of psoriasis vulgaris suggests that the inflammatory mechanisms are immune based and most likely initiated and maintained by T cells. However, the question of lymphocyte being an initiator of psoriatic events remains open so far. Clinical observations such as plaque symmetry, stress-induced onset or exacerbations, pruritus, and possibility of generalization, suggest a role of the nervous system and neurogenic inflammation in pathogenesis. A key to understanding the role of melanocyte in psoriasis is their ability to act as regulatory cell in maintaining epidermal homeostasis. In suggested hypothetic event, melanocyte, acting as a local "stress sensor", provide communicatory link between CNS and skin. The disease probably begins with so far unknown signal directed through neuronal network to the melanocyte, placed in the center of epidermal unit. That signal governs keratinocyte cellular activities and lead to reactive abnormal epidermal differentiation and hyperproliferation. Increased proliferation of basal keratinocytes and high metabolic demands creates angiogenesis in papillary dermis and elongation of dermal papillae. Stimulated melanocytes and basal keratinocytes become an important source of proinflammatory cytokines that attract lymphocytes in dermis. In conclusion, according to our hypothesis, lymphocyte infiltrate in psoriasis is secondary event rather than vice versa as presented in the literature.