Frede Olesen Professor, DrMedSc, GP, FRCGP(hon.) The Research Unit - - PowerPoint PPT Presentation

Frede Olesen

Professor, DrMedSc, GP, FRCGP(hon.) The Research Unit for General Practice, Aarhus University Chairman of the board of The Danish Cancer Society

FO@alm.au.dk

Denmark - City of Aarhus

A Danish national cancer rehabilitation initiative

needs – A case story needs – A case story

• Operated

cavity cancer followed by radiation and for oral chemotherapy

• Difficulty

in opening the mouth and without teeth

• No saliva,

impaired speech

• Eating problems – can
• nly eat soft

food severe weight loss ,

• Fatique
• Low

physical functioning

• Social isolation, loss of job
• Later – severe depression and

broken marriage severe depression and broken marriage

Discharge Treatment Late effects/psychsocial needs Follow-up appointment

Good chronic care: needs are different at different times and often mixed.

Different focuspoints: A:

• Somatic – social – psychological functioning

B:

• close to end of treatment reestablish normal functioning
• follow up plans – are they evidence based
• life has

Different focuspoints A:

• Somatic

late – social – psychological

Five Five regions running some General practice settings N = 2200/3500 GPs

A structure with 3 key stakeholders

• Denmark 5.5 mill inhab

Municipalites

A national cancer plan for rehabilitation

Third national cancer plan

• Integrated clinical pathways for

rehabililitation from hospital to primary care should be implemented

• The cancer survivor should be

given a survivorship plan at discharge or when relevant. The plan will be generic for the diagnosis

A national cancer plan for A national cancer plan for rehabilitation

Third national cancer plan national cancer plan

• All cancer survivors should be

screened and at and at effects and given appropriate treatment

• Valid screening tolls

should be implemented

• National clinical guidelines for

rehabilitation, late effects and controls be developed

• Controls

screening for late effects as well as recurrence of cancer screening for late effects as well as recurrence of cancer

What happens now??

money

• Most ressources will be allocated

to the municipalities

• Implementation through 2012 and local

programs supplemented with clinical guidelines

• Some money for implementation
• Most ressources will be allocated to the

municipalities

• Implementation through 2012 and local

programs ready by the end of 2012

rehabilitation and palliative care clinical pathway for cancer rehabilitation and palliative care

• Rehabilitation should address

physical training as well as psychological, social and existential needs

• rehabilitation

related programs for cancer patients by the end of

• Rehabilitation and palliative care are seen as a

continuum of care

• Rehabilitation should address physical training

as well as psychological, social and existential needs

• The hospitals and family doctors have an

important role in identifying rehabilitation needs and referral to municipality based rehabilitation

• The municipalities must establish rehabilitation

programs for cancer patients by the end of 2012

members The national patients organisation with some 500.000 members and a large funding agency

Patients voice Patients Collectring documentation for need Creating evidence Money for R&D Setting the political and prof. agenda Political lobbyism

Highly complex rehabilitation needs Rehabilitation and late effects requiring a specialized effort Supported self-care or limited needs

5% 25% 70%

Needs assesment is essential The Danish Cancer Society model for graduation of efforts

Partners throughout the three phases of cancer rehabilitation

Phase I Primary contact Days/weeks Phase II Early follow-up Weeks to months Phase III Follow-up and maintenance Months to years

Treating ward Physiotherapy (lymphoedema) Psychologist Physical training programme Patient school The Danish Cancer Society’s counselling centre Treating ward/oncological ward: Diagnosis specific rehabilitation programme Late effects unit Municipal offers General practitioner The Danish Cancer Society’s counselling centre Municipal rehabilitation (Physiotherapist, dietician, social worker, etc.) Psychologist Patient training, e.g. Stanford programme The Danish Cancer Society’s counselling centre

Hospital Hospital, municipality, General practitioner General practitioner and municipality

A pathway programme for cancer rehabilitation

• inspired by cardiologic rehabilitation

Thank you for your attention I look forward to further inspiration from you FO@alm.au.dk