Evidence on outcomes

Case management interventions for people with dementia and their caregivers were shown to reduce feelings of embarrassment and isolation, and to improve coping with memory problems or diagnosis of dementia, with additional effects for people with more severe impairment (one RCT) (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016). The intensity of behavioural problems at 18 months follow up (one RCT) and adherence to guideline recommendations (one RCT) were also shown to be improved by introducing case management (Reference Somme, Trouve and DraméSomme et al., 2012). Furthermore, patients’ access to services was significantly improved compared with standard care (Reference Somme, Trouve and DraméSomme et al., 2012). In terms of other patient-related outcomes, the majority of studies showed no impact of case management interventions, for example, regarding depressive symptoms (Backhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Khanassov and VedelKhannassov & Vedel, 2016; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015), functional status (Reference Backhouse, Ukoumunne and RichardsBackhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015) and quality of life (Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Khanassov and VedelKhanassov & Vedel, 2016; Reference Pimouguet, Lavaud and DartiguesPimouguet, Lavaud & Dartigues, 2010; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015; Reference Somme, Trouve and DraméSomme et al., 2012). No effects were shown on mortality (Backhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov,Vedel & Pluye, 2014; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015; Reference Somme, Trouve and DraméSomme et al., 2012), cognition (Reference Backhouse, Ukoumunne and RichardsBackhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Khanassov and VedelKhanassov & Vedel, 2016; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015), and activities of daily living (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov and VedelKhanassov & Vedel, 2016). In terms of health-system-related outcomes, the evidence for effects in the community was mixed. Significant positive effects were shown on length of hospital stay (two RCTs, Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014) and on the number of days per month in a residential home or hospital unit at 6 months (one RCT) and at 12 months (one RCT, Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015). Most studies analysing costs or cost-effectiveness showed no effects (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Pimouguet, Lavaud and DartiguesPimouguet, Lavaud & Dartigues, 2010; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015; Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013). Several studies included in the reviews showed significantly reduced institutionalization rates (n = 19, Backhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015), but more studies showed no effects (n > 30, Backhouse et al. 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Reilly, Miranda-Castillo and MaloufReilly et al. 2015; Reference Somme, Trouve and DraméSomme et al., 2012; Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013). Mixed results were also shown for emergency department visits (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013), for time to institutionalization to a residential home (Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013) and for hospitalization rates. For the latter, several RCTs showed no effects (Backhouse et al., 2017; Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015; Reference Somme, Trouve and DraméSomme et al., 2012; Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013) and only two RCTs reported intermediate effects (Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014). A meta-analysis of 16 RCTs revealed a significant positive effect after stratification for time to follow-up less than 18 months (Reference Tam-Tham, Cepoiu-Martin and RonksleyTam-Tham et al., 2013). In terms of profession-specific outcomes, the reviews found significantly improved guideline adherence and medication management (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014; Reference Khanassov and VedelKhanassov & Vedel, 2016). In a few studies, satisfaction was shown to be improved for both professionals (Reference Goeman, Renehan and KochGoeman, Renehan & Koch, 2016; Reference Khanassov, Vedel and PluyeKhanassov, Vedel & Pluye, 2014) and informal caregivers (Reference Pimouguet, Lavaud and DartiguesPimouguet, Lavaud & Dartigues, 2010). Moreover, receiving support from a case manager resulted in a decrease in depressive symptoms of caregivers (one RCT, Reference Pimouguet, Lavaud and DartiguesPimouguet, Lavaud & Dartigues, 2010).

Providing case management interventions to support older adults and their family caregivers (Reference Berthelsen and KristenssonBerthelsen & Kristensson, 2015; Reference You, Dunt and DoyleYou et al., 2012) was shown to improve patients’ emotional health (n = 1) and depression 6 months after intervention (n = 2). However, after 12 months, results for depression were mixed (Reference Berthelsen and KristenssonBerthelsen & Kristensson, 2015). Mixed results were also shown for functional status with four studies reporting positive and negative effects (Reference Berthelsen and KristenssonBerthelson & Kristensson, 2015; Reference You, Dunt and DoyleYou et al., 2012). One of the studies only showed positive effects on functional status in the long rather than the short term (Reference You, Dunt and DoyleYou et al., 2012). Furthermore, one study showed no effects on quality of life and the results of five studies on effectiveness of case management for older adults and their caregivers were inconclusive in terms of patient satisfaction (Reference Berthelsen and KristenssonBerthelson & Kristensson, 2015; Reference You, Dunt and DoyleYou et al., 2012). The results on mortality were not clear either with two studies reporting significant positive effects and five studies reporting no significant differences. However, providing case management was shown to decrease unmet needs compared with standard care (n = 3, Reference You, Dunt and DoyleYou et al., 2012). In terms of health system outcomes, some positive effects were shown, for example, decreased municipal care costs per family per year in Finland (n = 1) and significantly reduced admissions to long-term institutions in first (n = 1) and 18th month of intervention (n = 1). However, there were no differences after 24 months (n = 2). One study included in the review showed higher overall caregiver satisfaction, but two studies showed no improvements in emotional health, quality of life, sense of competence and mixed results in terms of caregivers’ depression.

For people suffering from Parkinson’s disease, integrating a multidisciplinary team approach in health care (Reference Prizer and BrownerPrizer & Browner, 2012) was shown to significantly improve Parkinson’s disease-related scores and patient mood (n = 1), health-related quality of life as well as depression scores, voice articulation and speech (n = 1). Caregiver mood was not shown to be improved and no health-system-related outcomes were assessed.

Palliative care

Skill-mix interventions in palliative care

Generally, fewer skill-mix developments in palliative care were identified in the literature compared with long-term care, and as a consequence the evidence on their effectiveness is limited. Nevertheless, skill-mix interventions directed at patients in palliative situations and their caregivers included various models and were assessed by six reviews (Table 7.2).

A Cochrane review that aimed to analyse the effects of a systematic and organized approach to collaboration with a multidisciplinary team involving at least two professions from different disciplines and targeting adult home hospice patients could not identify any study that met the inclusion criteria (Reference Joseph, Brown-Manhertz and IkwuazomJoseph et al., 2016).

Another Cochrane review (Reference Shepperd, Gonçalves-Bradley and StrausShepperd et al., 2016) assessed the effectiveness of any home-based end-of-life care interventions, including consultation, multidisciplinary care coordination, physiotherapy, informal help, nutrition and social care, and (if needed) 24-hour care, that provides active treatment for continuous periods of time by health care professionals, for example, specialist palliative-care nurses, qualified nurses, family physicians, palliative-care consultants, physiotherapists, occupational therapists, nutritionists and social care workers. In the majority of studies, the interventions were carried out by a multidisciplinary team.

Reference Dy, Apostol and MartinezDy et al. (2013) analysed the effects of interventions that focus on continuity, coordination and transition, including (i) involvement of the patient, the family or the caregiver, for example, through education; (ii) coordination with an additional provider to provide care; (iii) conducting care plans or (iv) introducing palliative-care specialists. Professions involved in the interventions were palliative-care specialist, nurse case managers, physicians, GP, nurse specialist, social workers, case coordinators and case managers.

Furthermore, Reference Carmont, Mitchell and SeniorCarmont et al. (2018) analysed interventions designed to engage GPs with special secondary services in integrated palliative care, including shared consultations or case conferences. Professions in the intervention were GPs and at least one other profession, for example, nurses, medical specialists or allied health professionals.

Another skill-mix innovation in palliative care was pain medication management educational interventions for family caregivers of patients with advanced cancer (Reference Latter, Hopkinson and RichardsonLatter et al., 2016). This included face-to-face education or training sessions, typically supported by written and other resources, opportunities for questions and discussion, and follow-up contacts for reinforcement or further coaching. Professions covered in those interventions were nurses, psychologists and researchers.

Reference Hudson, Remedios and ThomasHudson, Remedios & Thomas (2010) assessed the effectiveness of psychosocially and/or psycho-educationally based interventions for family caregivers including psychoeducation, psychosocial support, caregivers’ coping, symptom management, sleep promotion and family meetings. Professions involved in the interventions were not reported.

Examples of skill-mix innovations and new technologies/eHealth were not identified in the systematic reviews.

Evidence on outcomes

Interventions designed to engage GPs in integrated palliative care (Reference Carmont, Mitchell and SeniorCarmont et al., 2018) were shown to significantly improve patient functional status (n = 2), but to have no effects on patients’ quality of life or symptom burden (n = 2). Results from qualitative studies included in the same review suggest improved pain management, symptom control as well as increased safety for patients and family from both GP (n = 1) and patient perspective (n = 2). In terms of health-system-related outcomes, the studies showed a significant decrease in the number of hospital admissions. Furthermore, case conferences and shared care were both effective in reducing the length of hospital stay. Outcomes related to professions were shown to be improved in terms of strengthened service relationships, a better interprofessional communication and professional development (n = 2).

In their Cochrane Review, Reference Shepperd, Gonçalves-Bradley and StrausShepperd et al. (2016) showed that palliative patients receiving home-based end-of-life care were more likely to die at home than patients receiving usual care (n = 3 RCTs). In two RCTs, patient satisfaction was also shown to be slightly improved at follow up after 1 month. However, there was no difference after 6 months. Little effect on functional status (measured by the Barthel Index), psychological well-being or cognitive status (n = 1 RCT) was shown. The effects on 6-month mortality were unclear (n = 1 RCT). In terms of outcomes related to the health care system a significant reduction in health care cost between 18% and 30% in the USA was reported in two RCTs. But results on admission to hospital were mixed (n = 4 RCTs). Effects on informal caregiver outcomes are uncertain: Differences in caregivers’ satisfaction were only reported at 1-month follow up, but not at 6-months. Furthermore, caregivers of participants who had survived more than 30 days showed a decrease in psychological well-being (n = 1 RCT). In terms of caregiver bereavement response little or no effect was shown 6 months following death (n = 1 RCT).

Interventions that focus on continuity, coordination and transition were shown to significantly improve satisfaction in six studies included in the systematic review from Reference Dy, Apostol and MartinezDy et al. (2013). Only one study showed no effects. Effects on quality of life were more unclear with three studies showing positive effects and six studies showing no differences. The caregivers’ quality of life was reported to be significantly improved (n = 1) while no effects on their burden were shown in three studies. In terms of caregiver satisfaction, the results were mixed. A significant positive effect on caregiver satisfaction was shown in four studies and no difference was reported in two studies. Evidence on effects of single intervention components revealed improvements for patient- or family-related outcomes with family/patient involvement in six of nine studies. Using additional patient assessment was found to be significantly improved in nine out of twelve studies. Furthermore, providing coordination showed significant improvements in six out of nine studies on either quality of life or satisfaction. Improvements for palliative-care specialist involvement were shown in three out of five studies. In terms of outcomes related to the health care system, most studies showed no effects of single components. Only 5 out of 16 studies evaluating health care utilization, for example in terms of hospital admission and length of stay, found significant effects.

Providing psychosocially and/or psycho-educationally based interventions for family caregivers resulted in positive effects on caregivers’ depression (n = 2), on sleep quality (n = 1), as well as on their preparedness, competence and reward ratings (n = 1). Furthermore, a significantly increased level of comfort, closure and satisfaction was reported (n = 1). Another study showed significantly higher ratings of caregivers’ self-efficacy for helping patients to control pain and other symptoms (n = 1). It was also reported that implementing such interventions resulted in a reduction of unmet needs (n = 2). In general, caregivers’ perception of the intervention was shown to be positive (n = 3). A psycho-educational programme was shown to have significant favourable effects on caregivers’ perceptions of positive elements of their role (n = 1) and on family caregivers’ quality of life (n = 1). Effects on perceived burden of patients’ symptoms and their perceived burden of care tasks were inconclusive with one study showing significant positive effects and one study showing no significant benefit to caregivers while receiving a separate psychosocial support intervention. Effects on psychological benefits for caregivers are also unclear with one study showing positive effects and another study showing no significant benefit to caregivers’ psychosocial health or well-being. Reference Hudson, Remedios and ThomasHudson, Remedios & Thomas (2010) did not assess outcomes related to the patient or the health system.

In another review that aimed to analyse the effects of interventions focused on caregivers, providing pain medication management interventions to family caregivers of patients with advanced cancer (Reference Latter, Hopkinson and RichardsonLatter et al., 2016) was shown to significantly improve medication adherence in one RCT. Mixed effects were found on pain and on caregivers’ knowledge and beliefs about pain, although one study included in the review reported significant improvements in self-efficacy and perceived control over pain. Analyses are missing on health-system-related outcomes and outcomes related to professionals.

Education and training of the professions involved in the skill-mix changes

Most systematic reviews did not report details on the education and training of the professions covered in the studies. Only three studies on long-term care described the training in the skill-mix intervention groups, but not always in a systematic manner and they lacked details on the content, length and curricula. These studies reported that case managers received a specific advanced training (Reference Backhouse, Ukoumunne and RichardsBackhouse et al., 2017; Reference Khanassov and VedelKhanassov & Vedel, 2016; Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015). For example, Reference Khanassov and VedelKhanassov & Vedel (2016) described training of case managers in geriatrics/geronto-psychiatry, communication with patients and their caregivers and dementia home care. Another review reported that case managers with advanced training in six RCTs received training ranging from a 1-week intensive course to advanced practice education (3½ years) and additional special education in dementia care with a duration of 1 year (Reference Reilly, Miranda-Castillo and MaloufReilly et al., 2015).

Limitations and strength of evidence

A strength of this chapter is the comprehensive definition of skill-mix including not only all health professions but also explicitly including informal caregivers for people requiring long-term care and/or palliative care. However, several limitations exist. First, the number of reviews identified was low, particularly for palliative care. Second, the systematic reviews on long-term care presented an uneven coverage of conditions. Several systematic reviews exist for people with Alzheimer’s disease. For people with other conditions, such as Parkinson’s disease, the number of reviews was very low or non-existent, for example, for other functional impairments or mental health. Three Cochrane reviews were included of which two focused on palliative care. However, one of them did not identify studies that met the inclusion criteria. In sum, five meta-analyses were performed. The transferability of the findings across countries is limited as most studies were from the USA and there were only a small number of studies from Europe. Evidence on profession-related effects was limited across all reviews. The generally low quality of the evidence and heterogeneity of the interventions require cautious interpretation of the findings.

Summary of the evidence

The evidence suggests that case management for people with long-term care needs may result in some, albeit generally few, improvements for patients and their caregivers. For people with dementia, introducing case manager roles may be associated with reduced feelings of isolation and embarrassment of the condition, and may improve coping with memory problems. Furthermore, evidence provides indications that patients’ access to services and their compliance with guideline recommendations is improved. On other outcomes, such as functional status, depression or mortality, the evidence was either inconclusive or showed no effect. The reason may be that improvements for this target group are more difficult to achieve and to measure than for other conditions, an issue that should be investigated in future research.

For case management provided to older people living at home and their caregivers, results were different; for example, regarding informal caregivers and also in terms of health-system-related outcomes, where the evidence suggests that municipal costs may decrease after implementing case management interventions. Interestingly, and similar to dementia-specific case management interventions, a decrease in unmet service need was found.

For patients with Parkinson’s disease, introducing multidisciplinary teams may improve quality of life and other outcomes. Generally, the evidence was limited in terms of quantity and quality of effects.

On palliative care, the number of reviews covering people in their homes was low, but evidence suggests that home-based end-of-life care interventions may result in an increased likelihood of dying at home. Moreover, the majority of studies that analysed effects on patient satisfaction showed a positive impact. They also found improved caregiver satisfaction and a lower caregiver burden after introducing various skill-mix changes as well as a decrease in unmet needs. For patients’ quality of life and pain management the results were inconclusive. There is also some evidence of enhanced efficiency gains for health systems (for example, decrease in hospital admissions, reduced length of stay) and improved profession-specific outcomes (such as strengthened communication and service relationships) with increased collaboration across disciplines in palliative care.

Given the rapid increase in the number of people requiring long-term and palliative care over the past decade in Europe, and future projections, there is an urgent need for more and high-quality research on skill-mix requirements to provide quality care for patients in their homes, also including new technologies/eHealth.

Skill-mix changes and reforms

Most debates on the workforce in long-term care at home have focused on increasing the quantity of staff, with little attention paid to their skill-mix. Nevertheless, two major trends can be noted. First, current and expected future workforce shortages generate a need to attract more health professionals in long-term care (Reference De Klaver, van der Graaf and GrijpstraDe Klaver et al., 2013). To attract more health professionals, such as nurses or lay workers in long-term care, job opportunities are created for long-term unemployed, migrant populations or adults with disabilities (Reference De Klaver, van der Graaf and GrijpstraDe Klaver et al., 2013). At the same time, especially as better-qualified staff are a scarce resource, specific tasks from better-qualified staff are re-allocated towards less-qualified staff. Second, due to the complexity in care and in delivery of coherent, high-quality care, a few European countries, for example, Austria, Bulgaria and Serbia, implemented new roles for better-qualified staff (specialized in the care of older adults) or introduced new (multidisciplinary) teams or a new modality of teamwork to improve long-term care.

Examples specific to long-term care of creating job opportunities for unemployed or migrant populations are the introduction of geriatric home care assistants (Geronto service) in Serbia (Milicevic, forthcoming) (see Box 7.2), the 24-hour care workers in Austria (Habimana et al., forthcoming), or the assistants for disabled people in Bulgaria (Reference De Klaver, van der Graaf and GrijpstraDe Klaver et al., 2013). Examples of task allocation are physicians that are partially substituted by registered nurses or registered nurses that are partially substituted by less-qualified assistants. In the Netherlands, nurse practitioners, physician assistants and registered nurses are legally allowed to partially substitute GPs or nursing home physicians. However, because of a shortage of nurses, this does not happen on a regular basis (Reference Lovink, Van Vught and van den BrinkLovink et al., 2018) . In Belgium, health care assistants were introduced, providing basic care under nurse supervision (Sermeus, forthcoming). In Austria, Belgium and Denmark, informal caregivers (often family members) receive (psychological) support (Burau, Doessing & Kuhlmann, forthcoming; Habimana et al., forthcoming; Sermeus, forthcoming). Supporting and investing in informal caregivers might be a solution to compensate for shortages in formal caregivers, as informal caregivers can take over parts of the tasks of formal caregivers.

To improve quality and coherence of long-term care, some countries introduced new roles for professionals specialized in the care of older adults or new (multidisciplinary) teams. In Norway, the role of advanced geriatric nurses, that is nurse practitioners specialized in the care of older adults, has been implemented (Reference Henni, Kirkevold and AntypasHenni et al., 2018). In the Netherlands, a new type of baccalaureate-educated registered nurses, specialized in gerontology and geriatrics, work in long-term care services (Reference Huizenga, Finnema and RoodbolHuizenga, Finnema & Roodbol, 2016). To deliver coherent care at district level, the Visible Link programme (2009–2012) promoted the employment of district nurses (Reference De Klaver, van der Graaf and GrijpstraDeKlaver et al., 2013; Reference Grijpstra, de Klaver and SnijdersGrijpsta et al., 2013) (Box 7.3). The new role of these district nurses was formalized in 2014 (Batenburg & Kroezen, forthcoming). In addition, there was a shift towards self-managing home care teams (Batenburg & Kroezen, forthcoming). Since 2016, a number of Dutch municipalities have introduced social district teams, aimed at connecting supply and demand of care in neighbourhoods, focusing on the residents’ own capabilities (Batenburg & Kroezen, forthcoming). In Belgium, home-based occupational therapy was implemented to adapt the homes of patients to their conditions and to improve working conditions of home care professionals (Sermeus, forthcoming). In addition, nurses or social care workers received a case management role to allow older people to stay in their own home for as long as possible (Sermeus, forthcoming).

Implementation of reforms

Across Europe older or disabled adults want to stay in their own home for as long as possible and the political climate is favourable to long-term care at home; this has brought several countries to implement skill-mix innovations in home care (Reference De Klaver, van der Graaf and GrijpstraDe Klaver et al., 2013). There are differences in implementation between different roles, as some roles are more frequently implemented than others. In addition, the implementation of roles may differ across different regions within the same country. The introduction of new professional roles is usually supported by national governments. Incentives and facilitators to implement the skill-mix innovation may be (temporary) funding and legal changes. On the other hand, few large-scale reforms exist. Also, as most skill-mix innovations were implemented only recently, there is little evidence for the success of these innovations, though the formalization of the district nurse role in the Netherlands has shown positive results.

Skill-mix changes and reforms

Palliative home care is often delivered by the regular primary health care providers, such as family physicians and community nurses. Palliative care specialists are increasingly available in case of complex needs, yet some countries are still reporting a shortage of specialists in the field to ensure all people in need of palliative care receive it when needed. Overall, most skill-mix innovations identified have involved nurses more than health care professionals from other backgrounds. Task shifting has been introduced as a way to enhance teamwork and access to palliative care. The most frequent task shift identified was between doctors and nurses (Reference Knaul, Farmer and KrakauerKnaul et al., 2018). Often, new tasks were added to the job descriptions of professionals. Examples were coordination of services, case management and liaison functions between the patient, family and health care professionals (Reference Sekse, Hunskar and EllingsenSekse, Hunskar & Ellingsen, 2018; Reference Thomas, Wilson and BirchThomas et al. 2014; Reference van der Plas, Onwuteaka-Philipsen and Vissersvan der Plas et al. 2016). Box 7.4 presents an example of the role of case managers in palliative care in the Netherlands, who are nurses with a specialization in palliative care. Other examples of nurses working in expanded roles in palliative care are nurses from specialized palliative home care teams in Belgium, whose task has been to advise and support other health care providers (for example, family physicians and community nurses) in caring for palliative patients. While performing specialist palliative care tasks in close collaboration with family physicians these nurses enhance the quality of care delivery and at the same time have a bed-side teaching role (Reference Gomes, Calanzani and CurialeGomes et al., 2013; Reference Seow, Brazil and SussmanSeow et al., 2014). Workplace learning occurs through close collaboration with other professionals and as such can help professionals evolve and enhance quality of care delivery (Reference Mertens, de Groot and MeijerMertens et al., 2018; Reference Pype, Mertens and DeveugelePype et al., 2014, Reference Pype, Mertens and Wens2015).

Other examples of skill-mix innovations identified in palliative care were trainings for lay caregivers to get involved in the palliative care team by nurses, psychologists and social workers (Reference Farquhar, Penfold and WalterFarquhar et al., 2016). Receiving training and support from the health care team has been shown to help family members and other informal caregivers to better manage the stress and burden in such complex situations.

The most frequent innovation however was the introduction of team collaboration through introducing specialized palliative home care teams into the primary care field, along with the regular health care providers. This was the case in 39 out of 46 European countries responding to a European Association for Palliative Care survey (Centeno Cea, 2013), for instance in Germany (Box 7.5). These palliative home care teams consist of specialized nurses, physicians specialized in palliative care, psychologists and administrative support. The palliative-care nurses perform home visits, whereas the other team members mostly have a supportive and supervisory role. In specific patient situations with complex problems, a patient–health care professional contact can be made with the physician or the psychologist. These teams often have a role to support and advise the regular health care providers, although in other countries they actually deliver care in collaboration with the existing health care providers. Another example of introducing collaboration was through initiating a network of volunteers (Reference Woitha, Hasselaar and van BeekWoitha et al., 2015). These volunteers receive a basic training and their main task is to support the family caregivers.

Finally changing teamwork in existing multidisciplinary teams occurred through adding a palliative care leader, general practitioner and nurse, to a primary health care team (Reference Llobera, Sanso and RuizLlobera et al., 2017).

Implementation of reforms

Most innovations have been implemented at local level (in case of research projects or individual programmes, for instance case-manager projects) or at a national level (Reference Arias-Casais, Garralda and RheeArias et al., 2019). Yet, many countries are still reporting a gap in the supply of palliative care to provide timely care for those in need.

Some innovations have been spontaneous practice-based innovations driven by a strong sense of purpose for better patient care, for example, nurses taking up a coordinating role when observing a need. The recognition to improve the quality of patient care has been the main driver in these cases, in addition to the felt need to improve job satisfaction. Other innovations, such as the installation of specialized palliative home care teams or a network of volunteers, were supported by local or national governments. In the case of palliative home care teams, funding and official requirements towards professional qualifications were sometimes initiated and regulated by the government, which can be a policy lever to step up supply and standardize skills requirements.

The WHO recently initiated a pan-European programme that aims to strengthen palliative care competencies of and collaboration between involved health care professionals involved in palliative care (Box 7.6).