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Skip to 0 minutes and 8 seconds The initiative in the Netherlands, in South Holland, lies to the west of Rotterdam. It is based in Vlaardingen and covers four medium-sized towns. The area is known for its gin distilleries and is linked to the larger port of Rotterdam. One of the towns, Schiedam, is renowned for its windmills. Huub Schreuder is a coordinator of the service and explains how it works. Could you tell me something about how the service was set up? Because you were one of the founder members of it. Yep. 15 years ago, the network started. And we had an oncologist in the hospital. He was very anxious to make things better. And he looked further than the front door of the hospital.

Skip to 0 minutes and 58 seconds He knew that the people were going home and that there was something needed. But he didn’t know what. So he participated in the network and asked me, as a home-nurse specialised in oncology– he said, come to our ward. We have a meeting. And we want to discuss the patient and look what they needed, here in the hospital, but also in the first line. There it was started. The hospital consultant recognised part of the reason for the service’s success was that it covered a relatively small area with any one major hospital. And we have the service to a region, not quite big. And it is just four small villages and not a big town.

Skip to 2 minutes and 0 seconds So that’s why we had an opportunity to organise the palliative care quite easily. Because we have no problem with… at hospitals working in the same area. So we know each other. And we do it together. Payment for health care in the Netherlands is from an insurance-based system. So recognition for the need of the service was crucial for buy-in to the palliative care service. But other factors have been important to its success. Now, one of the factors is the good position we gave to the network coordination, the network coordinator, Huub, and his colleague but, also, the commitment of the professional from the oncology unit wards in the hospital.

Skip to 2 minutes and 57 seconds And what is very important, that we sought in a concept, and the concept was continuity of care from the home to the hospital or from the hospital to the home. But always from the view of and the focus on the client and his family system. The main concept for this initiative they describe as “transmural care,” which means health care geared to the needs of the patient, provided on the basis of cooperation and coordination between general and specialised caregivers, with shared responsibility and specification of delegated responsibilities. Key for this was the establishment of the team meeting with the hospital, involving the community nurses, GPs, and hospital team. One of the GPs with specialist training explains the benefits.

Skip to 3 minutes and 52 seconds That the specialists and the GPs are communicating better. They know how to find each other if there are any problems. And they know from each other what quality you have as a doctor or as a nurse. So this team meeting is crucial. Because this is where it brings together community and the hospital-based services. Yeah. And so, how would that happen without a team meeting? Or would you not think it would be the same? No, when the meeting isn’t there, it’s like most hospitals in the Netherlands.

Skip to 4 minutes and 38 seconds The specialist says to the patient that he can go home. And that’s it. That’s it. And a letter follows to the GP that the patient is at home. And the letter arrives two, three weeks later or a month later. And maybe, the patient already died. So that’s the old-fashioned way. It’s not working. It’s always too late. I like it if the specialist picked up the phone and called the GP. I have your patient here. I will let the patient go home. And this is what I have done and think it’s right for the patient. What do you think? So that they communicate with each other.

Skip to 5 minutes and 28 seconds There are different ways a patient may get referred to the meeting and referral to other services. Any cancer patient with complex needs can be referred. And often, a burden scale is used, which the oncology nurse explains. There’s a scale of about four pages. They can fill it in about theirselves, how they are feeling, what types of problems they are coming in the future. And there’s a scale of 0 till 10, also like a pain-scale. But this is for the mental scale. And we can help them. And when the scale gives 4 or higher, then it’s bad. Then, we can ask for help– physiologic, dietic, social worker, etc. However, not everyone is referred through the hospital.

Skip to 6 minutes and 22 seconds And crucial to this referral for patients, families, and health care workers is there is one phone number to call, which will take you to Huub and his team. Sometimes, the partner of the patient is calling with the network. We have one number for all palliative care issues. Every people in the area can phone that number and ask for help. So sometimes, the patients by itself or the caregiver’s family, the GP, the home nurse– everyone could ring and ask for help. And we need to ask for, what is the problem? What can I do? Or if something else needs to do something. It is not always that I have to do something. But at first, I listen. What’s the problem?

Skip to 7 minutes and 33 seconds And then, I can take the problem, if it’s necessary, into the meeting and ask advice at the other participants in the meeting. At the moment, only patients with cancer are referred to the team meeting. But there are plans to extend this service. And the government is requiring us to settle palliative care in the whole hospital. So our first task now is also to make palliative care possible and easy for the other patient group. And then, I think about COPD. I think about heart failure and also the old-age patients. So we are organising now a team in this hospital. We are organising MDOs in all the other departments.

Skip to 8 minutes and 27 seconds We get special nurses here in the hospital just to be sure that also the non-cancer patients get the same sort of care. There are additional needs from the GP perspective too. I would like that GPs have more involvement in the service. And well, I would like to see another meeting which gives more time for the patients who give problems in the care of palliative care. So more complex patients. More complex patients, yes. Yes, I would like that. And then, there’s more involvement for the GP, who sometimes knows patients for years and knows what kinds of people, kind of man or woman a patient is, or what his ideas about life and death are.

Skip to 9 minutes and 17 seconds All in all, the centralised approach to coordination makes the service work. There is a physical crossover of staff between the hospital and community, which not only means there is a sharing of information but also a build up of trust between the different professionals involved. Which leads to a more integrated experience for the patient. It’s trust for the patient. They can trust us. And that’s the most important thing.

Effective practice in palliative care: an example from the Netherlands

The second example of effective practice in palliative care comes from the Netherlands.

The initiative is part of the regional palliative care network ‘Nieuwe Waterweg Noord’, covering four medium-sized towns based in Schiedam. The initiative involves weekly meetings between the oncology unit of the regional hospital and community providers.

As you watch the film, consider what you think are important features in this service example.

You can also read about Margaret’s experience on page 37 in Integrated Palliative Care.

Additional reading

Further examples of integrated palliative care across Europe are available in the free book which accompanies this course (see ‘Downloads’ section at the bottom of this page).

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Palliative Care: Making it Work

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