Integrating Palliative care in HIV chronic care clinic at Wabulungu HC III, Mayuge District
In June 2010 the USAID Health Care Improvement (HCI) project commenced the palliative collaborative in Mayuge district with a goal of supporting scale up of palliative care services in low resource setting and sustains quality palliative care services in existing health system. At Wabulungu H CIII we have been providing HIV prevention, care and treatment services however with not much work done in relation to providing palliative care as defined by World Health Organisation (WHO) to our patients.
After the initial training in palliative care we found out that pain assessment and management in the chronic care clinic was lacking and we needed to improve the way we provide services to include proper identification and management of pain in the patients.
Two Staff from the health facility were trained in the palliative care and quality improvement skills and they were required to start the process of integrating palliative care at the health facility. On returning to the health facility they trained health providers presented their newly acquired knowledge on palliative care and invited all health providers to contribute towards integration of palliative care in the services provided at the health centre.
Change in documentation To start identification and assessment of patients with pain, a pain assessment column was added on the HIV care patient card. The clinicians were required to assess all patients they come in contact with by asking "Do you have pain?" and then document Y for yes and N for no as a response to the question in the pain assessment column. (See Fig 1 below) For those patients who respond Yes the clinician goes ahead to further assess the patients pain and score it to determine severity of pain and decide the management plan. Because there was no data system in place for pain management, the new pain assessment column allows the facility to track improvements in assessment and scoring of pain. (See Fig 2 & 3)
Fig 1: A patient's HIV care card with a pain assessment column
Fig 2: Shows a graph of patients asked whether they had pain
Fig 3: Pain scoring and prescription of medicines
In October 2010, requested Joy Hospice Jinja to make a stopover at the clinic on their way to their outreach point in the vicinity. Patients who are seen by the health facility and can benefit from the hospice care are booked for the twice a month stopover clinic. In the same way patients who need urgent attention and cannot wait for the stopover clinic are referred to Buluba hospital. To support the health facility with linkages to the community, volunteers identified by the health facility with consultations with the district were trained in September 2010 The two (2) trained community volunteers have been instrumental in providing health education at the health facility and in the community on palliative care services. Since October 2010, community volunteers referred over 50 patients with chronic pain to the health facility. With the success in integration of palliative care services in HIV clinic the team started to identify patients in the general outpatient department and introduced a register to enable follow up of those who were identified.
Even if we focused on physical pain management of all components of palliative care, we were able to identify patients with pain and provide appropriate management and referral. Integration of palliative care in lower resource setting is possible with change in the process of care to identify eligible patients to be managed. We were able to improve access to pain medicines for our clients even when we do not have them at our health facility.