Negotiating an efficient and egalitarian shift to ambulatory care, a challenge for the care of tomorrow

Illustration of a caregiver with a patient at Institut Curie. – Institut Curie Hugueni

  • While 2019 marks the end of the third Cancer Plan and we do not yet know the contours of the fourth cancer plan, a test dissects the stakes and specificities of the fight against the disease that kills most today in France.
  • Researchers are particularly interested in the shift to ambulatory care, which must be accompanied at the risk of increasing inequalities.
  • How? 20 minutes looks at several lines of thought.

"We are in 2019 in the last year of the 3rd cancer plan, so it's time for reflection," said Thierry Breton, director of the National Cancer Institute (INCa). An analysis that can draw on rich research in social sciences including a book, which has just been published and was presented Thursday at the Center for Sociologist Organizations, The fight against cancer in France*. This book deals in particular with the challenges ahead, among which the
ambulatory shift and its serious consequences, especially for caregivers.

Transfer the burden of the community to families

"As I come out of chemotherapy, fortunately I had my family and friends, it's essential for morale and healing," recalls Sylvie Faiderbe, who has battled cancer and three relapses in twelve years. Go home early, when patients are ready why not, but I went home very worried. It would be reassuring that loved ones receive advice. "

Relatives hit hard by an early and sometimes early return home. " With the shift to ambulatory care, hospitalization time is shortening, which increases the pressure on carers ", analyzes Emmanuel Jammes, in charge of health policies at the
League against cancer.

This is why the outing must be organized with the greatest care, pleads the association. And professionals must ensure that the return will be in good conditions for the patient, but also his entourage. "We should check that the home is equipped and measure the impact on loved ones," says Emmanuel Jammes. Because if you're a mother of young children with a husband who works as a liberal, financial sacrifices and lack of rest can weigh heavily. "There are chances that some of these patients will come back through the emergency door," he warns.

The link between city and hospital

This home care boom will not happen without better coordination of health professionals. "More and more care will take place in the city and no longer at the hospital, posing major issues of coordination between the city and the hospital and also safety of care – when a patient takes his chemotherapy at home, how will we ensure the follow-up of the treatment and also reassure him and identify any undesirable effects? ", interrogates
Patrick Castel, co-author of the book and sociologist at
Center for Sociology of Organizations.

Encouraging the work hand in hand of health professionals, the city and the hospital, imagine care as a journey, it is precisely the ambition of the health strategy of Emmanuel Macron. "It's been twenty years since I hear that we have to work better together, I'm waiting to see, because it requires changing mentalities," nuance, dubious, Emmanuel Jammes.

Digital, a tool, but not a miracle

This necessary organizational change can be based on new digital tools. Telemedicine first, which allows a patient to contact his specialist without leaving his bed. But also a lot of connected objects and applications, which allow to imagine an accurate remote monitoring and ease. For example, Delphine Richet is launching her start-up,
Continuum, an application that aims to accompany cancer patients treated at home by oral therapy. "The hospital, nurse, pharmacist, GP will be able to track health data," she says.

But this support is not suitable for all audiences. Having an expensive and modern object will make a beautiful leg for the elderly, little connected, those who live in the white zone … "The belief in a miracle tool is to be nuanced by the prism of the inequalities that digital can accentuate and the necessary transition time for professionals and patients to equip themselves, says Pierre-André Juven, researcher and co-author of this essay. A study in an Ehpad had also revealed that to offer a teleconsultation to an elderly person, it involves mobilizing two people to install it, help him take notes … "

"Digital is good, digitalized human is better"

Not optimal for everyone, but also dangerous for the future of care. According to Emmanuel Jammes, "it is a means, a facilitator but it should not in any way substitute for the human relationship. Some apps and bots ranswer questions with generalities while each patient is different. Finding the right ratio to these new tools, so that they effectively help health professionals without replacing them is part of the bets to take up. "The digital is good, the humanized digital is better," summarizes Delphine Richet.

Expert patients and pharmacist, important crutches

But in a context of shortage of doctors, who could support these often poor and isolated patients? "The patient-experts, responds Sylvie Faiderbe, who undergoes training at the
University of patients to become patient-expert. "From patient to patient, the things that are said and understood are not the same as with the caregivers, this relationship of equals, with someone seasoned who has reflected on his experience, I would have liked to have it …. "

Problem: the training of expert patients is now stammering … "We can never put an expert patient behind the 400,000 new patients per year, tempers Emmanuel Jammes. Today, it is based on associations and volunteering. But the question of the remuneration of these patient-experts deserves reflection. "

Another path suggested by Sylvie: "pharmacists have a key role to play. I, between two cures, I was all the time stuffed at my pharmacist, they know us and know when a patient suspends his treatment. They should be able to alert expert patients, the nurse or a referring physician. "

* The fight against cancer policies in France, EHESP Press, January 2019, 18.99 euros.

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