From Hospital to home (from ideal to real life)

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(1)

From Hospital to home

(from ideal to real life)

Michele Vitacca

Divisione di Pneumologia Riabilitativa IRCCS Fondazione Salvatore Maugeri –

Lumezzane (BS)

3

°

Ideal life

Diagnosis, cure and care

Diagnosis, cure and care Rehabilitation Rehabilitation prevention prevention

Physical

activity

Training

Relapses control

maintanance benefits: the challenge !

Drugs adherence

(2)

Telesupport Home care Intermediate units Hospital at home Tele rehabilitation Palliative care Dedicated office Specialized rehabilitation units HMV Indication Information Education Feasibility Discharge Follow-up Yes Non

Hospice

Low tech hospitals

Alternatives

Training

Don’t forget the caregiver!

Impact of intensity of care

Family diseases

Am J Public Health 2002;92:409-13

Education

Hernandez 2003 Paneroni 2012 Adams 2007 Bach 2000 Escarrabill 2012 Vitacca 2011 Gonçalves 2009 Vitacca 2004

(3)

Discharge Checklist

Respiratory symptoms

Transportable ventilator, battery powered

Autonomy: environmental aids, NIV masks, ventilation compatible with wheelchair, anticipatory planSuction machine

Cough assist

Home care strategy – outreach/community

Risk management: ventilator breakdown, masks, filters tubingDaytime ventilation – mouthpiece, nasal interfaceAdvanced planning

Family support, travelTech support Daily living activitiesRoom setting

Dedicated offices

H

MMG

Specialist

Pt/ health team communication

H face to

face visit

phone

SMS

E mail

Twitter

Video

conference

Home

visit

Telesupport

5. GP, NURSE & COMMUNITY SOCIAL SERVICE 2. OXIMETRY

3. CALL CENTER

4. IN-HOSPITAL SANITARY STAFF T A HO ME 1. PATIENT/CAREGIVER AT HOME Teleassistance Network Teleassistance Network

(4)

Advanced Care planning

SIMULTANEOUS CARE

Linee guida italiane e standard per

l’ Assistenza Domiciliare Respiratoria

Italian guidelines and standards for Respiratory Home Care Coordinatori

V. Galavotti (Mantova), G. Idotta (Cittadella, Padova), G. Garuti (Correggio, RE) Rassegna Apparato Respiratorio 2010

Commissione Operativa P. Berardinelli (Milano), G. Biscione (Roma). G. Busato (Bolzano), G. De Donno (Mantova)

E. Faccini (Treviso), D. Fiorenza (Lumezzane,BS), G. Fiorenzano, (Cava dei Tirreni), M. Galetti (Mantova), F. Gigliotti (Firenze), G. Iuliano (Milano), ), M. Lazzeri (Milano), A. Marcolongo (Cittadella,PD), G. Riario Sforza (Milano), E. Sabato (Brindisi), C. Scarduelli. (Bozzolo, MN), S. Squasi

(Bassano del Grappa,TV), R. Tazza (Terni), G. Vezzani (Reggio Emilia )

Expected benefits Reduction in the length of hospital stay No inappropriately increased rate of H readmissions Reduced utilization of hospital resources Support for therapeutic measures and devices Involvement and training of family to promote independence Intervention during episodes of acute exacerbations Maintenance and development of "activities of daily living“ Uncertain effects in critically ill survivors

Real life

chronicity

Severe

chronicity

End of life

Healthy at risk

High High

Health

Costs

Care level

(5)

P A T I E N T H o s p i t a l H e a l t h c a r e H o m e s e t t i n g G E N E R A L P R A C T I T I O N E R S o c i e t y E m e r c e n c y S y s t e m t r a n s p o r t F o l l o w u p S y s t e m s H o m e S e r v i c e c o m p a n y Family laboratory ER rehabilitation devices clinic telemedicine ICU bourocracy Social service Attentions and abandons Nurse visits therapist

Complexity of a CRF patient word

M. Vitacca 2009

DATI DI PNEUMOLOGIA

ministero

21.500

Tavolo Ministeriale 2011 Unpublished data

RIABILITAZIONE RESPIRATORIA

NMD patient survay

Still inadequate communication of the diagnosis Failure to take global care

Lack of psychological support for the family Absence of pre tracheostomy information Unskilled nurses

Lack of qualified home care

Lack of control over the quality of home care Difficult to manage the patient in the hospital Limited presence of physicians

Fonte AISLA

Criticisms in ALS care

the caregiver burden !

Tsara V. Respiration 2006;73:61-7

50% of caregivers face

problems in social relation

8,1%

87,9% 1,6% 2,4%

Caregiver Ventilator Drugs Others

Estimation cost of HMV in USA

Bach J. Chest 1992;101:26-30.

(6)

The criteria were: High dependency, tracheostomy,

necessity of more than 12 hrs of MV, distance from Hospital more than 30 km, presence of frequent hospitalisations. The criteria were:

High dependency, tracheostomy,

necessity of more than 12 hrs of MV, distance from Hospital more than 30 km, presence of frequent hospitalisations.

Monaldi Arch Chest Dis 2007; 67: 3, 0-00

N°792 home ventilated pts N°792 home ventilated pts

Power failure

Ventilator malfunction

Accidental disconnection

Circuit obstruction

Mask fit

Tracheotomy:

Blocked Falls out

Cannot be replaced after changing

Medical problems

Thorax 2006;61:369-71 17% 18 MINUTE VENTILATION PRESCRIBED (l/min) 6 8 10 12 14 16 ACT U AL -P RE SCRI BED (l/ m in ) -8 -6 -4 -2 0 2 4 (A)

Quality control

Quality control

Farré R. Intensive Care Med 2003;29:484-6

H

Survivors

at "catastrophic illness condition"

Unroe Annals of Internal Medicine 2010; 153: 167–175

After 1 year:

9% at home without dependencies

26% at home with dependencies

21% at home highly dependent

44% dead

COST: $ 3.5 mil /year survivor

Effects on QOL, and caregiver

stress

ICU

ICU

H LTCF NSF Reha Home

Ann Intern Med. 2012;156:673-683

Intervention:

Home plan included

education (4 individual and 1 group session),

an action plan for identification and treatment of exacerbations, and

scheduled proactive telephone calls for case management.

All received a COPD informational booklet.

Conclusion:

The plan in patients with severe COPD had not decreased COPD-related

hospitalizations when the trial was stopped prematurely.

(7)

N° totale pz. 123 N° totale visite/prestazioni 231 M/F 41/46 Età anni 63+17 Diagnosi BPCO 35% SLA 28% Tracheo % 60% Distanza Km 35+16

Monaldi Arch Chest Dis 2009

Prestazione eseguita %

Sostituzione di tracheocannula 64 % modifiche della prescrizione di O2 37 % prescrizione di monitoraggio della spO2 24% cambiamenti dei parametri della VM 4%

nuovo adattamento alla NIV 7%

Prescrizione nuovi presidi per

O2-terapia e VM 36%

Indicazione ricovero ospedaliero in

elezione 9%

Indicazione a programma di FKT

domiciliare 6%

Exists a protocol for Advance

directives ?

Rassegna di Patologia dell’Apparato Respiratorio 2011; 26: 303-309

%

Where patients have died?

Survey su 180 pts

%

family, carers, non specialist

community Healthcare professionals

(8)

%

Symptoms: breathless and cough

2006 progetto TELEMACO

2010 Nuove Reti Sanitarie (30 UO)

for transfer COPD from the hospital to the territory

T eles or vegli an za B PCO

Estimated 1500 patients enrolled in Lombardy

Educational Hospital training

Telemedicine with pSatO2

+

Activation on demand Cough assist device plus RT home visits

(9)

Multidisciplinarity Network/organisation No extra costs High centers’ expertize Care coordination Less travels Specialized settings (weaning, palliation) Pt association involvement

WHAT PTS ASK (1)

MV

complications

QOL

speech

Humidification

New ventilators

usability

Tech skills

Organisational skills

WHAT PTS ASK (2)

Managing

Home equip.

in Hospital

Quality control

/risks

Travels/pts

transport/mobility

Sustainability/equity

/rembursement

Centers’

expertize

Where H

admissions for

ARF

Comparative

effectiveness

MISSING THEMES

Decrease in H

Procedure

standardisation

New care delivery

models

Competitions among

actors

Performances

reimbursement

Providers role

WICH OUTCOMES ?

(10)

Any model of continuity of care

should be:

preventive

predictive

customized

sustainable

integrated

technological

But especially partecipated

(patients less passengers and more

conductors their health)

Figure

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References

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