International Comparisons
Moments of Truth: The Challenges of Co-ordinating Care For Older Persons
A European Research Project Has Spotted Innovative Developments in Long-term Care Delivery / Opinion
October 2005
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By Bernd Marin, Kai Leichsenring, and Manfred Huber
European Centre for Social Welfare Policy and Research
More and more older persons are in need for different kinds of health and social care services, thus creating a complex situation where management and coordination tasks have to be planned, accomplished and financed by different organisations, professionals, often with the additional help of family carers. Older persons who are living alone frequently need a range of different services due to functional incapacities after illness or discharge from hospital. Another challenge for care coordination are older persons who are at risk to lose their autonomy – at home or in an old-age home – due to chronic-degenerative or other diseases.Many of these situations become visible and/or occur only at short notice. These are the "moments of truth" for social and health care systems with respect to their ability to respond to the needs of older persons. In all countries, the general policy objective is to promote community care in order to prevent care in nursing homes as long as possible. In reality, however, older persons and their family carers are often confronted with the following situations:
- The hospital discharges an older person in need of long-term care on Friday afternoon without any earlier notice to family members or community care providers.
- The community care service is taking an older person in charge without a multidimensional needs assessment and thus without an individual care plan. The home nurse recognizes problems of hygiene at the home of one of her patients but does not inform the home help service, or family members.
- The GP prescribes an X-ray to an older patient living alone without informing him/her about the availability of transportation services.
Most important results
- In all countries, a first step is the horizontal coordination or integration of community care services (home help and home nursing). Another pathway is to establish a case manager at the interface between hospital and community care services. Model ways of working have challenged the ‘pessimistic’ view of entrenched professional cultures representing an insurmountable obstacle to collaborative working – multi-disciplinary teams have developed many strategies for managing inter-professional collaboration, for developing a culture that valued the complementarity of the individual professions, as well as formal and informal communication to improve the understanding of each other’s roles, and being able to see that their holistic approach made a difference to clients.
- Most importantly, objectives and the target group of integrated care services have to be defined and shared by all stakeholders. Model ways of working assess clients’ needs based on a commonly used method, using the same language to draft an individual care plan mutually agreed between all professionals, the client and his/her family.
- Even in most developed welfare states mainly female family members are providing the bulk of long-term care tasks. One of clients’ and their carers’ most important needs in accessing services is information and guidance to and through a system with which they are not familiar at all: one-stop information counters, counselling centres and staff that is able to provide an overview of all opportunities in long-term care are most welcome. Model ways of working foster quick solutions in complex situations based on pooled social and health care information – in this connection information technology (IT) can be applied most efficiently if common access to and regular updates of shared data-bases are guaranteed.
- The case manager (or also: care manager) covers the most crucial professional role in integrated long-term care provision – respective education and training designs have to be defined to promote this new job profile and to develop skills of staff. In this connection, the eminent labour shortages in long-term care call for a quick and effective upgrading labour conditions in the whole sector: the dissemination of case management skills should be part of such programmes. Model ways of working have shown that a mix of different skills and a clear job definition are key, rather than charging only health care staff with case management tasks.
- Providers of services and clients do not always have the same interest. Even if, to date, ‘user-orientation’ can be found in service-charters, it is most difficult to reconcile long-term care client’s expectations with the organisational requirements of personal services, e.g. to guarantee always the same personal carer throughout the whole year. Service providers thus have to improve their communication skills and the ways in which they assess, monitor and evaluate their performance. Even model ways of working have shown difficulties with respect to these aspects of integrated care provision.
- Most model ways of working are projects depending on vulnerable funding sources. In some cases even positive evaluation studies did not help to turn model projects into mainstream services. The only ‘(almost) consolidated direct service model’ which was analysed in Denmark demonstrates that, apart from affirmative framework conditions concerning investments in innovative approaches, long-term funding and organisational development are necessary to achieve a sustainable impact. The small municipality of Skævinge had invested since 1984 in its ‘Health Centre Bauneparken’ and has collected significant results: even though the number of older persons has increased significantly over the past 20 years the operational expenditures have decreased over the period due to the preventative focus of the integrated care scheme; there is no waiting time for apartments in the Health Centre or for domestic health and social care services; the preventative efforts have resulted in a surplus of capacity that has been used mainly to establish an intermediate care facility at the Health Centre in order to prevent unnecessary hospital admissions – consequently, the number of days at hospitals has been reduced by 30-40 per cent for all citizens in the municipality; over the last 10 years no citizen from the municipality staying in a hospital had to wait for discharge after having finished treatment as those citizens are cared for either in the intermediate care facility at the Health Centre or in the citizens’ own home; the municipality’s use of and expenditure to national health insurance is below the average of all other municipalities in the county.
Further reading:
- Leichsenring, K./Alaszewski, A. (eds) (2004) Providing Integrated Health and Social Care for Older Persons – A European Overview of Issues at Stake. Aldershot: Ashgate.
- Billings, J./Leichsenring, K. (eds) (2005) Integrating health and social care services for older persons – Evidence from nine European countries. Aldershot: Ashgate (in print).
Contact:
Dr. Kai Leichsenring
European Centre for Social Welfare Policy and Research
Berggasse 17, A-1090 Vienna (Austria)
leichsenring@euro.centre.org
www.euro.centre.org/procare