Abstract
Early palliative (PC) among patients with non-oncological chronic conditions is not such extended as among patients diagnosed with cancer. This is partially due to the lack of clear and consistent indicators and triggers to define an ‘early’ or ‘timely’ initiation of PC services as the identification of palliative needs can be complex and uncertain in the transitions to advanced chronicity.
The EU-funded project InAdvance (ref.: 825750) aims to implement strategies to identify older patients that could benefit from PC services sooner in the trajectory of chronic diseases. For that, a multi-centre RCT has been performed in four European Cities (Amadora-Portugal, Inverness-UK, Thessaloniki-Greece and Valencia-Spain) where the NATPD tool (Needs Assessment Tool for Progressive Diseases) has been implemented in 183 patients and their informal caregivers. Additionally, 29 healthcare professionals (HCPs) have been involved for the performance of the study and implementation of the NATPD.
Thus, the aim of this study is to identify factors that have enabled and hamper the implementation of the NATPD intervention in each service provider context.
For that, an implementation-science approach has been considered during the RCT using the Consolidated Framework for Implementation Research (CFIR) as the main theoretical model which is able to evaluate implementation progress. On the one hand, questionnaires were developed and filled by HCPs during the trial implementation. Additionally, a more qualitative approach was used through the performance of: i) focus group sessions before the start of the trial to detect potential barriers and facilitators for the upcoming implementation of the NATPD intervention; and ii) another set of group interview sessions to gather further information about the NATPD implementation on the four sites in terms of the intervention performance, its impact on the participants, associated costs, acceptance and future sustainability and adoption.
Before the start of the trial, HCPs reported that working with patients with palliative needs that they are not completely able to respond is stressful. Once the trial started, HCPs considered the NATPD as an advantage to support patients in need of PC as this tool was helping them to know more about patients’ needs and preferences. Moreover, the intervention was considered as effective and they experienced a reduced burnout while working with patients with palliative needs. On the opposite, the support received by leaders and managers in the clinical settings to implement the intervention was not enough along time.
Two relevant changes were introduced to the clinical teams thanks to the NATPD implementation: i) a more formal and structured referral process to avoid decision-making processes based on ‘clinical instinct’; ii) discussion of each patient case by a multidisciplinary team of HCPs where consensus regarding the most appropriate referrals was made.
In sum, HCPs considered the NATPD an easy and useful tool to initiate conversations with patients and their relatives/informal carers and implement integrated PC. Consequently, the impact of InAdvance on older patients with complex chronic conditions are perceived and approached by HCPs: from a more individualized perspective and joining forces with colleagues from different clinical backgrounds.