Rethinking primary-palliative care collaboration: insights from a mixed-methods study in a spanish region

Both specialist- and primary-level palliative care services are needed if high levels of access to palliative care are to be achieved. The Alava province in the Autonomous Community of Spain's Basque Country is undertaking a quality improvement initiative to optimize collaboration between primary care professionals and the region's community-based palliative care service, called Equipo de Soporte de Atención Paliativa (ESAP).

To inform the quality improvement initiative, this study explores the experiences of primary care professionals and the palliative care team regarding the provision of palliative care in the region and to explore their respective needs and preferences regarding future care models.

A mixed-methods approach was applied. Quantitative data were collected through a survey, followed by focus group interviews with primary care professionals and the palliative care service. Descriptive statistics were used to summarize the quantitative data. Inductive thematic analysis was used to analyze qualitative data.

A total of 118 primary care professionals responded to the survey (23% response rate); 54% were nurses and 42% physicians, while 86% and 14% were located in urban and rural areas respectively. Seventeen professionals (10 primary care, 7 palliative care) participated in three focus groups. When palliative care support was needed, the primary care participants consulted the ESAP service most often (69%), followed by a hospital-at-home (HaD) service (19%). Of respondents who had collaborated with the ESAP service (n = 73), 40 (55%) felt that it should continue being a support service and 18 (25%) felt that it should take over providing all home-based palliative care. In the qualitative analyses, four themes were identified as facilitating primary palliative care: (1) The ESAP team; (2) Collaboration, (3) Education and training; and (4) Supports for patients. Barriers included: (1) Workforce challenges; (2) Increasing patient loads; (3) Ensuring care continuity; and (4) Unfamiliarity with the ESAP service. Several potential improvements were identified but some diverging opinions were noted among participants. The palliative care team described the relativity of complexity, the support role being nuanced, resource constraints and unrealistic expectations in some cases.

This study offers important insights to inform ongoing strategies to improve collaboration between primary care professionals and specialist palliative care teams. While most primary care participants saw themselves providing primary palliative care and valued the ESAP team's support, some favoured delegating the care of patients with palliative needs-particularly those nearing end of life-to another services.