214-1292 / Palliative Care Platform for Continuity of Care

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Regional Coordination of Palliative Care


Quality improvement project

GOP Description
Implementation level
Clinical settings
Madrid Emergency Services Coordination Centre. Offering services to Home Care, primary care, Palliative Care services, specialist services in Public Hospitals, public and independent Units, and pre-hospital emergency services
To improve Palliative Care services in the Community of Madrid promoting continuity of care:
-To give confidence and support to carers at home, avoiding unnecessary admissions to emergency services.
-To support professionals responsible of the care of patients at home.
-To manage Palliative Care resources in the Community of Madrid.
-Those patients with palliative care needs in which continuity of care is provided out of hours.
-Those professionals in Primary Care, prehospital emergency services (SUMMA 112) and specific Palliative Care teams involved in the care of the patients.
1.Creation of a specific palliative care platform as a model of continuity of care staffed by professionals with advanced training in palliative care, whose functions are:
-To coordinate Palliative Care in the Community of Madrid 24/7 making available to professionals attending patients at home, all the information properly updated that includes evaluation of needs, treatment and care plan at any care setting.
-Manage existing resources, optimizing the connections with emergency services putting in place when needed a specific system of advice to professionals during 24 h.
-Being the manager Center of the Regional Register of palliative care.
2.Include the use of shared protocols and systems for access to up-to-date clinical information patients.
3.Inclusion in the 24 hour care program, of a training and research project, as well as training in the management of the phone in the context of health assistance for palliative care professionals.
Timeframe implementation
Implementation tools available
The following tools have been developed to aid the work of professionals in order to ensure continuity of care:
‘Infopal’: It is a powerful integration tool of all relevant information, so that those involved in the palliative process of all and each one of the palliative care patients have access to information from physical, emotional, social and spiritual aspects, constantly from their place of work. This is a major breakthrough in the improvement of continuity of care.
‘gespPAL’: it is a set of all processes and procedures that grant the flow of palliative care in the Community of Madrid
Implementation cost
The salary of 6 doctors and 6 nurses, the professionals that form part of PAL 24
Method used to measure the results
Through a computerized record to measure monthly activity that makes a retrospective analysis between January 2013 and April 2014.
-There is a patients’ ascending trend in contact cases to Pal 24:
21098 contacts in 2013 vs 26310 contacts in 2014.
-93.2 % of the contacts have malignant disease
-The main consulting reason is pain , 11.7 %
-Requests for admission to an inpatient Palliative unit come 8 % from ESAD (domiciliary Palliative support teams), 17 % from hospitals without specific Palliative Care Team and 75 % from specific Palliative Care support teams.
-Waiting time from bed request until allocation :
-43.71 % beds were allocated the same day
-56.29 % wait up to 3 days
Analysis of the results
Palliative care requires an important continuity of care. To have easy access, ‘comfortable’ as could be the phone, with immediate availability of trained professionals, is one of the advantages of this model. It makes carers to feel better and safer and reduces unnecessary visits to emergency departments, allowing carers to solve their questions.
It also allows quick communication and support to other health professionals, looking for advice or assessment on how to look after their patients with palliative care needs. At the same time this 24h model, plans and coordinates management of resources, allocating them as the clinical need arouses.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
There is no specified text here
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
Other information
Other information about the GOP that you would like to add (Link or attached document)
-Pal 24 has improved the coordination of care of patients with palliative care needs amongst different care settings and this way it has also improved the quality of palliative care provided. This is corroborated with the expression of satisfaction received from patients and carers.
-At the same time it has reduced the number of pre-hospital emergency units (SUMMA 112) teams mobilized to the patient´s homes, mobilizations to emergency departments and unnecessary hospital admissions, and therefore has improved the management of economic resources.
-87% of the cases are resolved with telephone advice, 10 % need a prehospital emergency unit to be mobilize to the patient´s home and in 3% one of the two professionals on duty need to travel to patient´s bed side.
-That way PAL 24 accomplishes its objective: to improve public socio-sanitary attention in Palliative care in the Community of Madrid increasing its quality, safetynet and problem-solving capacity.201511300150398514_202_GOP_EAPC blog.docx