SERVICE 11.Geriatric and Pallitative Health care.pptx

palliative health care

1. UHC – HWC – CPHC Training to Medical Officers of Mini Clinic Directorate of Public Health and Preventive Medicine Government of Tamilnadu

2. Service: 11 Geriatric and Palliative Health Care Services

3. Introduction Owing to the increase in life expectancy and decline in birth rate, worldwide the elderly population is rapidly growing There are basically two broad categories of elderly: those between 60 and 75 years (young old) and those over 75 years (old-old) The first category is comparatively physically active and mentally alert The second category is physically frail with different type of impairments like vision, hearing, locomotion etc. These people need special care

4. Age Related Changes in Various Body Systems

5. Genitourinary and Reproductive System Menopause takes place between the early 40s and 50s after which the ovaries reduce their production of female sex hormones The main effect of testosterone deficiency is on penile erection, premature ejaculation and loss of libido. Sperm production generally does not end until the mid 70s The number of nephrons per kidney decreases by 30–50% between ages 25 and 85 years The GFR declines nearly 50% by 90 yrs of age The kidney becomes less responsive to sodium loss The bladder capacity decreases from 500 ml – 600 ml to about 250 ml UTI and urinary incontinence in both elderly males and females, and benign prostate hypertrophy, and malignancy of prostate in males are quite common

6. Goals of Care of Elderly People

7. Maintaining Self-Care For keeping an older adult independent, healthy, and able to manage any chronic conditions in their home environment Preventing Complications of Ageing or of Existing Chronic Conditions Regularly assess a patient’s current status for any changes or complications that might require new interventions or changes in treatment Delaying Decline Address strength and physical abilities as well as promote and reinforce healthy behaviours Care providers should address each individual’s goals to achieve the highest possible quality of life. a personal basis

8. Domains of Care of Elderly

9. Promoting Healthy Aging amongst the Elderly Avoiding polymedication : They should be instructed to avoid self medication. There should be judicious use of medicines Social Activity : Encourage the elderly to remain socially active by involving themselves in certain activities/joining certain NGOs, spending time with friends etc. Maintain Daily Routine: Ask to fix a time for each activity during the day e.g. eating, napping, sleep at night and getting up in morning, walk, religious activities etc. Regular Health Checkups : They should undergo all the investigations at least once in a year Physical Activity: Thirty minutes walk in the morning as well as in the evening is the best physical exercise Personal Hygiene : Encourage to carry out their own personal hygiene routines as much as possible. The safety in the bathroom should not be overlooked

10. Urinary Problems

11. National Programme for Health Care of The Elderly (NPHCE) The objectives are : Provide preventive, curative and rehabilitative services to the elderly persons at various level of health care delivery system of the country Strengthen referral system, to develop specialized man power and to promote research in the field of diseases related to old age To provide accessible, affordable and high-quality long-term comprehensive and dedicated care services to an Ageing population Creating a new “architecture” for Ageing To build a framework to create an enabling environment for a “Society for all Ages”. To promote the concept of Active and Healthy Ageing. Convergence with AYUSH and other line departments like Ministry of Social Justice and Empowerment.

12. Elderly in India Three key demographic changes—declining fertility, reduction in mortality and increasing survival at older ages—contribute to population ageing resulting in increasing share of Elderly (60+) in population. Census 2011- 8.6 % of Indian population is elderly. By 2050- 19 % of Indian population.

13. Health Implications- Increasing morbidity

14. Program Components Dedicated geriatric care facilities through primary health care system of service delivery and secondary care level Tertiary level geriatric care through a. National Centre for Ageing b. Regional Geriatric Centres 3. Secondary level geriatric care through District level Hospitals 4. Primary level geriatric care through CHCs, PHCs.

15. Program Strategies Community based primary health care approach including domiciliary visits by trained health care workers. Dedicated services at PHC/CHC level including provision of machinery, equipment, training, additional human resources, IEC etc. Dedicated facilities at District level Hospitals with 20 bedded wards, additional human resouces , machinery and equipment, consumables & drugs, training and IEC.

16. Program Strategies ( cont …) Strengthening of Regional Geriatric Centres to provide dedicated tertiary level medical facilities for the Elderly, introducing PG courses in Geriatric Medicine and in-service training of health personnel at all levels. Information, Education & Communication (IEC) using mass media, folk media and other communication channels to reach out to the target community. Continuous monitoring and independent evaluation of the program and research in Geriatrics and implementation of NPHCE.

17. National Centre for Ageing, Guindy Only 2 in India- AIIMS, Delhi & King Institute of Preventive Medicine, Guindy , Chennai Rs.126.87 crore 8.64 acres of land 200 beds Currently under construction

18. Regional Geriatric Centre, Chennai At Rajiv Gandhi Govt. General Hospital, Chennai. Provides referral treatment, research, manpower development, developing and updating training materials for various levels of health functionaries, developing IEC materials and guidelines . 8 bedded exclusive geriatric ICU

19. District Level Hospitals Either at Medical College Hospitals or at District Head Quarter Hospitals 18 Medical College Hospitals & 13 District Head Quarter Hospitals

20. G.O (Ms) No. 373 H&FW (EAP II-2) Department dated 23.10.2017 issued for: Year Establishment Human Resources (per district) 2015-16 5 Districts (MCH) 1 Consultant Medicine, 6 SN, 1 Physiotherapist, 2 Hospital Attendant, 2 Sanitary Attendant 2016-17 3 Districts (MCH) 2017-18 23 districts (10 MCH & 13 DHQH)

21. Medical College Hospitals ( RoP Approvals) 2015-16 2016-17 2017-18 Coimbatore Thanjavur Dharmapuri Madurai Vellore Kanchipuram ( Chingelpet ) Salem Villupuram Kannyakumari Tirunelveli Karur Trichy Pudukkottai Sivagangai Theni Thiruvarur Thoothukudi Thiruvannamalai

22. RoP 2017-18 : 13 DHQHs WITH GERIATRIC UNIT Ariyalur Cuddalore Dindigul Erode Krishnagiri Nagapattinam Namakkal Perambalur Ramanathapuram Thiruvallur Tiruppur The Nilgiris Virudhunagar

23. Infrastructure facilities 20 bedded ward Elderly friendly ward- Anti-skid floor, side rails Western toilet with side rails

24. Equipments provided Ward Equipment Fowlers cot ECG Machine Portable Bipap Multi- para Monitor Alpha beds Ambu bagLaryngoscope Infision pumps Glucometer Physiotherapy Equipment Electronic Cerivical com Lumbar Traction Short wave diathermy Wax Bath Inter Ferential Therapy unit Ultrasound therapy unit Parallel bars Stationary cycle, Mariners wheel, Pulley, TENS, Walkers

25. At CHC level (Block PHC) Implemented in - 2018-19 385 Block PHCs of Tamil Nadu Geriatric OP- weekly twice Home- Care Services by ‘ Community Palliative & Geriatric Care Nurse’ - visits 5 households/ day, 6 days a week, 26 days a month. - The nurse will carry a Home-care kit.

26. Why home care? Reduces physical difficulties of the patient associated with travelling The care giver does not have to sacrifice a day’s wage in order to take the patient to health facility Reduces expenses associated with vehicle, food, lodging etc Reduce OOPE

27. Home-Care kit containing necesssary drugs & equipment

28. Services provided by a Community palliative Care Nurse in a Nutshell Provide basic nursing care services at home of the patient (Home-Care) Provide End of life-care Teach care givers techniques of patient care Communicate effectively with patient upholding his/her dignity Communicate effectively with care givers for proper decision making Deliver essential drugs and equipment to patient

29. National Program for Palliative Care (NPPC) It is estimated that 7 % of the population of Tamil Nadu require palliative care. Life expectancy in Tamil Nadu has increased from 61.9 years for females and 59.4 years for males in 1990 to 73.5 years for females and 68.9 years for males in 2016. DALY loss due to NCD and Injuries amounts to 79.6% as per Global Burden of Diseases report Impact of NCD and aging, palliative care has become very relevant in this context at present and future. 30

30. National Program for Palliative Care (NPPC) It is estimated that 60% of people who are dying would benefit from palliative care. Palliative care primarily aims to relieve suffering and improve quality of life. This involves inclusion of their family members as a part of care giving services. NPPC was launched in the year 2016-17 in Tamil Nadu 31

31. Principles of Palliative Care Provides relief from pain and other distressing symptoms Integrates the psychological and spiritual aspects of care Offers a support system to help patient families to cope with patient through the entire course of illness until death and also throughout the bereavement process undergone by the family Social care is the cornerstone of Palliative Care 32

32. Pain Palliation - why it is required? Pain is the most common reason to seek medical care 80% of people with severe pain do not receive adequate treatment. Cancer patients, 28% suffer from pain at diagnosis and around 60 to 84% in advanced stages. This stresses the need for pain Palliation 33

33. Palliative Care Palliative care is provided as Institution based Palliative care Home / Community based Palliative care 34

34. Implementation of Palliative care services in Tamilnadu Institution based Palliative care implementation phases 35 Phase DHQH Medical Colleges 1 8 2 2 10 - 3 9 3 4 - 17 Total 27 22

35. Implementation of Palliative care services in Tamilnadu Community based palliative care implementation phases During June 2018 to January 2020, Community Based Palliative Care Services have been implemented around 287 blocks covering all HUDs by placing one Staff Nurse in each of the blocks trained in Community based Palliative Nursing Care. All 385 blocks in Tamil Nadu will be covered under Community based Palliative Care Programme by 2020-21. 36

36. Institutional based Palliative Care Institutional based Palliative care caters beneficiaries at institutional / facility level such as Medical college hospitals and District Head Quarters hospital. Morphine dispensation at District Head Quarters was the Key element under the programme . About 2.34 lakh Morphine tablets have been issued between July 2019- Jun 2020. 37

37. Community based Palliative Care Community based model is patient centric, takes into account culture value system and reduces the expenses associated with visiting facilities. Under Home or Community based palliative care beneficiaries are provided services at door steps. Family care givers also get benefitted as the service provider provides psychological support to family care giver. Most financially sustainable and socially viable model. About 1.26 lakh individuals have benefited from home based palliative care since the time of initiation till date. 38

38. Trainings Conducted under the Programme Block Medical Officers and Medical Officers 3 days training on Palliative care and Pain management to facilitate the dispense of Oral Morphine tablet. Staff nurses 3 days training on Palliative care 10 days training on Foundation for palliative care at Kerala 39

39. G.Os Issued 40 Sl. No Name of Activity Subject G.O details 1 Establishment of Pain and Palliative Care Units in 10 Phase I districts National Health Mission - Establishment of Pain and Palliative Care Units in 10 Districts - Sanction order- Issued G.O (Ms) No.19 dated 12.01.2018 issued 2 Proposal for Amendment of Phase I districts G.O (Ms) No.19 dated 12.01.2018 issued National Health Mission - State Health Society - Tamil Nadu - Pain and Palliative Care Units in 10 Phase I districts - Orders issued - Amendment - Orders - Issued G.O (Ms) No. 31 dated 8.2.2019issued 3 Establishment of Pain and Palliative Care Units in 10 Phase II districts National Health Mission - Establishment of Pain and Palliative Care Units in 10 Districts namely Kancheepuram, Coimbatore, Villupuram, Vellore, Thanjavur, Erode, Trichy, Salem, Tirunelveli and Kanyakumari Districts - Sanctioned - Orders Issued G.O (Ms) No. 146 dated 24.04.2018 issued 4 Establishment of Pain and Palliative Care Units in 12 Phase III districts National Health Mission - Establishment of Pain and Palliative Care Units in 12 Districts namely Ariyalur , Dharmapuri, Karur, Madurai, Nagapattinam, Nilgiris, Perambalur, Pudhukottai ,Sivagangai, Theni, Virudhunagar and Chennai - Sanctioned -Orders - Issued G.O (Ms) No. 579, dated 14.12.2018 issued 5 Proposal for Amendment of Phase III districts G.O (Ms) No. 579, dated 14.12.2018 issued National Health Mission - Establishment of Pain and Palliative Care Units in 12 Districts namely Ariyalur , Dharmapuri, Karur, Madurai, Nagapattinam, Nilgiris, Perambalur, Pudukkottai , Sivagangai, Theni, Virudhunagar and Chennai - Orders Issued - Amendment Orders Issued G.O (Ms) No. 101, dated 8.3.2019issued 6 Establishment of Pain and Palliative Care Units in 17 Medical college hospital and creation of 68 posts of Staff Nurses National Health Mission - Establishment of Pain and Palliative Care Units in 17 Medical college hospital and creation of 68 posts of Staff Nurses (Regular and contract) and 34 posts of Palliative Care Hospital Workers through outsourcing-administrative Sanction - Orders Issued G.O (Ms) No. 541, dated 29.11.2019issued 7 Implementation of palliative care policy for state National Health Mission -Implementation of palliative care policy for state -Approved- Orders Issued G.O (Ms) No. 292, dated 07.06.2019issued

40. Modules / Policies Developed 41 Tamil Nadu - State Palliative Care Policy

41. Future Plans in Palliative Care Programme Block level integration of long term care including Palliative, Geriatric, NCD services, Mental Health etc. in a phased manner Aims to provide home based Palliative care nursing services at all blocks. Services provided through trained staff nurse designated as ‘Community Palliative Care Nurse’ @ 1 per block are providing home based Palliative care nursing services for those who are bed-ridden along with physiotherapy services. Integration with UHC programme. 42

42. Beneficiaries 43 Coimbatore District Villupuram District The Nilgiris

43. Beneficiaries 44 Kallakuruchi HUD

44. Thank you