THE ROLE OF THE DISTRICT QUALITY IMPROVEMENT TEAM IN STRENGTHENING INTEGRATION OF PALLIATIVE CARE INTO CHRONIC CARE AND OTHER SERVICES IN MAYUGE DISTRICT, UGANDA
Management of persons living with HIV has been ongoing for decades globally with provision of Antiretroviral Therapy to improve quality of life implemented in many districts of Uganda including Mayuge. However, despite all the measures put in place to provide comprehensive HIV prevention, treatment, care and support, palliative care with the emphasis to pain management among such patients in Mayuge district has been inadequate leaving clients in uncontrolled pain.
Baseline data from the 9 health facilities offering Pre ART/ART services indicate that there was no proper identification, assessment and management of pain in any of these facilities. In July 2010, the USAID Health Care Improvement (HCI) Project in collaboration with Ministry of Health (MOH) trained health workers from 9 health facilities offering Pre-ART/ART services and 3 members from the District Quality Improvement Team (DQIT) in Palliative Care with the aim of scaling up Palliative Care in Mayuge district using a site level quality improvement approach. Four (4) months after training, data collected from 7 sites showed that there was very little improvement in the indicators that were identified to be monitored (Identification, assessment and management of pain among HIV positive patients). It was to this effect that the DQIT embarked on measures to ensure that Palliative care with emphasis to pain management is fully integrated into chronic care and other services, and set objectives are achieved in the 9 health facilities.
The first step was to guide health workers draw flow charts to demonstrate how process to integrate palliative care at health facility level would be possible and guide the health providers to identify gaps that need to be addressed. It was realized that 8 out of the 9 health facilities that offer Pre ART/ART services lacked a mechanism of triaging of clients so that those with pain could be easily identified. For facilities that did not have a triage process, it was instituted to reduce work load of the clinicians who initially had to combine triage with clinical assessment. This role was allocated to nurses, and expert clients.
In addition the DQIT oriented all health workers including those who missed the initial technical training on the importance of proper assessment and scoring of pain which leads to better management of patients. All site QI teams were guided and selected persons responsible for pain management in these health facilities. Identification and management of other causes of pain such as malaria was emphasized.
The DQIT also availed pain assessment and management tools and encouraged all sites to put them on walls for easy reference during the management of patients with pain and this was reviewed during each visit. 7 out of the 9 health facilities have the charts on walls . Health workers were reminded to regularly hold education sessions on palliative care so as to bring everybody on board and reports on sessions held were reviewed during monthly visits.
Coaching health facility teams also focus on integrating palliative care in other services mainly outpatient department (OPD) other than HIV chronic care clinic so as to ensure that other patients with chronic conditions and have pain are identified and managed appropriately. To this effect 3 health facilities have already done so and have established a palliative care register in OPD for documentation.
All 9 health facilities were guided and currently developed monthly Action plans. Phone calls to health facilities about how far palliative care action plans had been implemented are regularly made before and achievements and challenges are discussed during the mentoring and coaching visits as a basis for re-planning.
Increasing access to pain medicines
Majority of the health facilities had WHO pain ladder Step 1 medicines specifically Paracetamol tablets under the “push system” of acquiring drugs for lower health facilities in Uganda. The DQIT discussed and decided that Health Centre level IV which are under the “pull system” and able to make medicine orders would include requisitions to cater for other lower health facilities which provide chronic care but are not allowed to order medicines. 3 out of the 6 health facilities under the "push system" have benefited from this arrangement.
Mayuge district has 3 doctors who are legally eligible to prescribe oral morphine used to manage severe pain. Availability and prescription of oral Morphine in health facilities with no trained prescribers was identified as a major challenge. Therefore the DQIT identified a medical clinical officer who with the funding from HCI was able to enroll for a clinical palliative care course. She will therefore be able to prescribe, mentor and supervise other clinical officers in 3 health facilities who may prescribe morphine as well as support the district in following palliative care issues. In the absence of the required pain medicine in health facilities, emphasis on referral instead of giving the available but wrong pain medicine was done and monitored on the client cards.
Technical Support to health facilities
To support health facilities not performing well, the DQIT scheduled clinical mentors’ support especially on HIV clinic days to mentor and coach health facilities teams implement chronic care. The clinical mentors were drawn from well performing health facilities and supported 3 health facilities to improve in general management of HIV positive patients including pain management.
Ensuring proper documentation
Poor documentation was identified during onsite coaching and mentoring. The reasons for poor documentation specific for each health facility were identified and addressed during DQIT visits. The DQIT guided and oriented site teams on proper filling of client cards and helped 6 health facilities that had not made a column for documenting pain management on the client card to do so. All site QI teams were also oriented on proper filling of documentation journals that could help them monitor performance on chosen indicators. As a result 7 health facilities are documenting changes in the documentation journals and this is reviewed during the DQIT monthly visits.
The DQI team presented palliative care progress report at district meetings and called for support from all those in different capacities.
Results from 7 health facilities where Palliative care was integrated into Chronic Care services showed improvement in the indicators being monitored from November 2010 when the DQIT decided to strengthen redesigning of interventions in these clinics.
Identification: There was improvement in the identification of patients with pain when The DQIT guided QI site teams on triaging patients with pain and identifying persons responsible for pain management at each health facility.
Assessment of pain: Scoring of pain among patients improved after intensfying mentoring and coaching.
Pain management: Health workers started giving the right pain medicines after scoring pain among patients with pain.
The commitment and continuous support of the DQIT helped clinics redesign changes that led to improvement.
Training health workers to make changes that would lead to improvement is not enough. Continuous mentoring and coaching by the DQIT is key to ensure that interventions have been implemented and plans for sustainability are worked on together.