From Hospital to home (from ideal to real life)

Transcription

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 prevention Physical activity Relapses control Drugs adherence Rehabilitation Training Home care Diagnosis, cure and care maintanance benefits: the challenge! 1

2 Intermediate units Dedicated office HMV Indication Training Telesupport Tele rehabilitation Information Education Home care Hospital at home Palliative care Specialized rehabilitation units Non Feasibility Yes Discharge Alternatives Hospice Low tech hospitals Follow-up Don t forget the caregiver! Education Am J Public Health 2002;92: Hernandez 2003 Paneroni 2012 Vitacca 2011 Vitacca 2004 Escarrabill 2012 Impact of intensity of care Family diseases Adams 2007 Bach 2000 Gonçalves

3 Discharge Checklist Dedicated offices Respiratory symptoms Transportable ventilator, battery powered Autonomy: environmental aids, NIV masks, ventilation compatible with wheelchair, anticipatory plan H Suction machine Cough assist MMG Home care strategy outreach/community Risk management: ventilator breakdown, masks, filters tubing Daytime ventilation mouthpiece, nasal interface Advanced planning Family support, travel Tech support Daily living activities Room setting Specialist Pt/ health team communication H face to face visit T A Telesupport phone 1. PATIENT/CAREGIVER AT HOME 2. OXIMETRY 3. CALL CENTER Home visit SMS Teleassistance Network HO ME Video conference E mail Twitter 4. IN-HOSPITAL SANITARY STAFF 5. GP, NURSE & COMMUNITY SOCIAL SERVICE 3

4 Advanced Care planning Linee guida italiane e standard per l Assistenza Domiciliare Respiratoria Italian guidelines and standards for Respiratory Home Care Rassegna Apparato Respiratorio 2010 Coordinatori V. Galavotti (Mantova), G. Idotta (Cittadella, Padova), G. Garuti (Correggio, RE) 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 SIMULTANEOUS CARE 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 Healthy at risk Health Costs chronicity Severe chronicity Care level End of life High High Real life disability Clinical complexity Comorbidities Social frailty 4

5 E H m Ge Ha Er Fo l Nc om t E le h Rn l Ac os HL y Pw ea S Ar o sp y Tu ve c Rs Ip i At Ec H C NS eo t at m y li t sc e Tr to Ia em s On mp e N sa t Ep nt Ro yi r n t g 04/04/2013 devices Complexity of a CRF patient word ICU rehabilitation ER bourocracy Social service DATI DI PNEUMOLOGIA ministero Nurse visits therapist telemedicine clinic Family laboratory RIABILITAZIONE RESPIRATORIA Attentions and abandons M. Vitacca 2009 Tavolo Ministeriale 2011 Unpublished data NMD patient survay the caregiver burden! Estimation cost of HMV in USA Criticisms in ALS care 8,1% 1,6% 2,4% 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 50% of caregivers face problems in social relation Tsara V. Respiration 2006;73:61-7 Caregiver cost 87,9% Caregiver Ventilator Drugs Others Fonte AISLA Bach J. Chest 1992;101:

6 Quality control Monaldi Arch Chest Dis 2007; 67: 3, 0-00 Farré R. Intensive Care Med 2003;29:484-6 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. N 792 home ventilated pts Thorax 2006;61: Power failure Ventilator malfunction Accidental disconnection Circuit obstruction Mask fit Tracheotomy: Blocked Falls out Cannot be replaced after changing Medical problems H ACTUAL - PRESCRIBED (l/min) MINUTE VENTILATION (A) 17% PRESCRIBED (l/min) Survivors at "catastrophic illness condition" Ann Intern Med. 2012;156: ICU H LTCF NSF Reha Home ICU Unroe Annals of Internal Medicine 2010; 153: 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 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. The plan was associated with unanticipated excess mortality. 6

7 Monaldi Arch Chest Dis 2009 Exists a protocol for Advance directives? N totale pz. 123 Prestazione eseguita % N totale visite/prestazioni 231 Sostituzione di tracheocannula 64 % modifiche della prescrizione di O2 37 % M/F 41/46 Età anni prescrizione di monitoraggio della spo2 24% cambiamenti dei parametri della VM 4% nuovo adattamento alla NIV 7% Diagnosi BPCO 35% SLA 28% Tracheo % 60% Distanza Km Prescrizione nuovi presidi per O2- terapia e VM Indicazione ricovero ospedaliero in elezione Indicazione a programma di FKT domiciliare 36% 9% 6% Rassegna di Patologia dell Apparato Respiratorio 2011; 26: Survey su 180 pts family, carers, non specialist community Healthcare professionals Where patients have died? % % 7

8 % Symptoms: breathless and cough 2006 progetto TELEMACO 2010 Nuove Reti Sanitarie (30 UO) for transfer COPD from the hospital to the territory Activation on demand Cough assist device plus RT home visits Telesorveglianza BPCO + Estimated 1500 patients enrolled in Lombardy Educational Hospital training Telemedicine with psato2 8

9 WHAT PTS ASK (1) WHAT PTS ASK (2) Multidisciplinarity MV complications Pt association involvement Network/organisation Organisational skills QOL Specialized settings (weaning, palliation) No extra costs Tech skills speech Less travels High centers expertize Care coordination New ventilators usability Humidification MISSING THEMES Managing Home equip. in Hospital WICH OUTCOMES? Decrease in H Comparative effectiveness Quality control /risks Providers role Procedure standardisation Where H admissions for ARF Travels/pts transport/mobility Performances reimbursement New care delivery models Centers expertize Sustainability/equity /rembursement Competitions among actors 9

10 CONCLUSION 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) 10