Strengthening Community End-of-Life Care through Implementing Measurement-Based Palliative Care.

The increasing demand for palliative care in New Zealand presents a potential threat to the quality of service delivery. One strategy to overcome this is through the implementation of valid and reliable patient-reported outcome measures. This mixed-methods study aimed to (1) implement measurement-based palliative care (MBPC) in a community palliative care service in Auckland, New Zealand; (2) evaluate the clinical utility of MBPC perceived by clinicians; (3) describe patient characteristics as measured by the Integrated Palliative Care Outcome Scale (IPOS), the Australasian Modified Karnofsky Performance Scale (AKPS), and Phase of Illness (POI); and (4) evaluate the internal consistency of the IPOS. Participants were over 18 years of age from a community outpatient palliative care service. In a phased approach to implementation, healthcare staff were educated on each instrument used for patient assessment. Uptake and internal consistency were evaluated through descriptive statistics. An interpretive descriptive methodology was used to explore the clinical utility of MBPC through semi-structured interviews with seven clinical staff members. Individual patient assessments (n = 1507) were undertaken predominantly on admission, with decreasing frequency as patients advanced through to the terminal phase of their care. Mean total IPOS scores were 17.97 (SD = 10.39, α = 0.78). The POI showed that 65% of patients were in the stable phase, 20% were in the unstable phase, 9% were in the deteriorating phase, and 2% were in the terminal phase. Clinicians reported that MBPC facilitated holistic and comprehensive assessments, as well as the development of a common interdisciplinary language. Clinicians expressed discomfort using the psychosocial and spiritual items. Measurement-based palliative care was only partially implemented but it was valued by staff and perceived to increase the quality of service delivery. Future research should determine the optimal timing of assessments, cultural responsivity for Maori and Pacific patients, and the role of MBPC in decision support for clinicians.

Can formal collaborative methodologies improve quality in primary health care in New Zealand? Insights from the EQUIPPED Auckland Collaborative.

INTRODUCTION: Auckland District Health Board was one of four District Health Boards to trial the Breakthrough Series (BTS) methodology to improve the management of long-term conditions in New Zealand, with support from the Ministry of Health. AIM: To improve clinical outcomes, facilitate planned care and promote quality improvement within participating practices in Auckland. METHODS: Implementation of the Collaborative followed the improvement model / Institute for Healthcare Improvement methodology. Three topic areas were selected: system redesign, cardio-vascular disease/diabetes, and self-management support. An expert advisory group and the Improvement Foundation Australia helped guide project development and implementation. Primary Health Organisation facilitators were trained in the methodology and 15 practice teams participated in the three learning workshops and action periods over 12 months. An independent evaluation study using both quantitative and qualitative methods was conducted. RESULTS: Improvements were recorded in cardiovascular disease risk assessment, practice-level systems of care, self-management systems and follow-up and coordination for patients. Qualitative research found improvements in coordination and teamwork, knowledge of practice populations and understanding of managing long-term conditions. CONCLUSION: The Collaborative process delivered some real improvements in the systems of care for people with long-term conditions and a change in culture among participating practices. The findings suggest that by strengthening facilitation processes, improving access to comprehensive population audit tools and lengthening the time frame, the process has the potential to make significant improvements in practice. Other organisations should consider this approach when investigating quality improvement programmes.

Reproductive health for displaced populations

The provision of reproductive health(RH) services by humanitarian agencies to displaced populations is relatively new. Until recently, the needs of displaced people in emergency settings were often ignored. During the eighties, attempts were made to address the problem, and in the last few years increasing attention has been paid to these needs in emergency contexts. In particular, recognition of the major threat posed by STDs and AIDS and growing media attention to sexual violence among displaced populations has highlighted the importance of the RH agenda in emergency settings. A longside changes in RH provision in stable settings, the move to implement RH services for displaced populations was accelerated after the International Conference on Population and Development in 1994. The Conference ser reproductive health within a rights framework and highlighted the needs of displaced populations. However, despite the increased recognition of RH concerns in emergencies, in reality the agenda has proved difficult to implement. Some aspects raise ethical and moral concerns to which humanitarian agencies have different attitudes. Bilateral agencies, non-guvernmental organisations and donors are grappling with difficult decisions as to what services they should provide and how to ensure servces are safe and effective. This is also happening in stable settings. In the absence of good data on both needs and impact of RH service provision in emergencies, much of the emphasis on safe provision falls to the judgement of field based practitioners, with important implications for training and appropriate resourcing at that level. In this paper available information about reproductive health among displaced populations is presented. Policies of a number of actors are also described and examples of current RH programmes and the issued facing those attempting to implement them are explored. (AU)