Best practices in seniors’ home care: International forum THE FINNISH AND DANISH CASES B Y P R O F V I R P I T I M O N E N T R I N I T Y C O L L E G E D U B L I N F O R P R E S E N T A T I O N T O T H E F O R U M C O N V E N E D B Y T H E B R I T I S H C O L U M B I A M I N I S T R Y O F H E A L T H A N D M I C H A E L S M I T H F O U N D A T I O N F O R H E A L T H R E S E A R C H V A N C O U V E R 1 5 J A N U A R Y 2 0 1 4
Key questions What have been the main driving forces for reforms in home care for seniors? What have been the reform strategies ? What changes are underway in how home care is organised, financed, provided, governed and regulated, and assessed? What evidence exists to show the impact of system- level policy changes (e.g. structure, financing) to home care and the outcomes for seniors and their caregivers?
Structure of this presentation Shared drivers & trends Key features of Danish system Key features of Finnish system Important differences Distinctive features and ‘learning’ that might be most useful for policy planning elsewhere Things that these systems struggle with…the ‘do not do this at home’ bit ‘Take home’ messages
Shared drivers & trends Concern about costs De-institutionalisation Intensification: channelling supports to people with highest level of care needs Performance management & measurement Growing diversity of providers Highly trained home care staff: most have received 1- 3 years of formal training (and increase in training envisaged)
Strong orientation to home care (3/4 of expenditure) Denmark Large share of older population in Denmark receipt of home care (nearly 1 in 5 among the 65+, nearly half of the 80+) Universality: home care is free of charge Still overwhelmingly provided by the public sector Preventative approach: backed by several randomised controlled trials
Growing diversity of providers, Finland fuelled by outsourcing (of all Avustaa lukemisessa; Kirjoittaa purchases costing ≥100 K) and tax yhdessä kirjeitä credits that incentivise direct Avustaa vaatteiden valinnassa; Pitää huolta kodin kasveista purchase of services, especially by Pelata kortti- ja muita pelejä; the better-off Koristella kotia esim. juhliin Less strongly oriented to home care Järjestää ja säilyttää reseptit; Valmistella kauppalistat than Denmark (about 50:50 home Valvoa ja opastaa TV:n käyttöä and institutional care) Opastaa tietokoneenkäyttöä Entitlement more finely graded; Postittaa kirjeet ja asiakirjat user fees apply based on income and Ostaa kirjoja, aikakaus- ja usage sanomalehtiä Suunnitella vierailuja, ulkoiluja Attempts to integrate family care ja matkoja into the formal care system Vierailla naapurien ja ystävien luona Intensification: greater fusion of Ylläpitää valokuva-albumeita; Arkistoida perhehistoriaa health and social care (Kröger and Leinonen 2012)
Key differences Role of family and markets stronger in Finland than in Denmark Source: Szebehely 2013
Key differences (continued) Care is free in Denmark; user fees (up to a limit) apply in Finland Standard needs assessment in Denmark (‘Common language’); no nationwide eligibility criteria in Finland Large variations between local authorities in Finland; little variation in Denmark
Distinctive features & foci: Denmark Improving and measuring quality (in tandem with the endeavour to ensure efficient use of resources) Autonomy, service user empowerment and responsibility, reablement and preventative approaches Provision Contracts: specify the parameters and aims of the care provided Care recipients has rights, but also responsibilities Where possible, the aim is rehabilitation
Distinctive features & foci: Finland Inter-linking of health and social care tasks through home care personnel training Home nursing + home help = (regular) home care, delivered by ‘practical nurses’ Home care now more medicalised, integrated with home nursing
Finland: Involving family carers Number of family carers in receipt of formal supports doubled between 1990 and present Proportion of older adults whose carers receive formal support has increased by a third ‘ Familialism by default’ / ‘supported familialism ’ the model for all but the frailest Rights of supported family carers include three days of respite care per month
The less successful stories… Failure to combine standardisation with individualisation – resulting in increasing complexity, “the reverse of what was intended” (Rostgaard 2012) Key problem: ‘Common language’ that specifies four levels of need, with specific supports associated with each level, and very specific (by the minute) time allocations for each support – monitored through palm pilots and other IT applications (‘barcode tyranny’) Attempts to increase flexibility within need/support categories
Key emphases / recommendations: % of older people in receipt of home care has And attempts to declined – older adults a more diverse group do better…2013 …partly thanks to hjælp-til-selvhjælp (‘help to Danish home help oneself’) care commission Call for more evidence on the effects of report rehabilitation; financial incentives for providers Better use of IT applications Age limit of preventive visits raised to 80
Key recommendations Recommendation 14 Recommendation 7 “The Commission “The Commission recommends that the recommends that target group for municipalities restrict the rehabilitation includes detailed management of both individuals who may time and individual benefit from a time-limited services in order to provide rehabilitation, as well as greater flexibility and more people with very complex room for professionalism needs who may benefit in the encounter between a from long-term support citizen and employee .” with a rehabilitative purpose .”
…and attempts to do better: Finland 2013 law on services for the older person – impact to be analysed at admin and population levels… www.thl.fi Key deliverables for local authorities: Assessment of care needs within seven days of request Named care liaison person for each care recipient Feedback must be sought from service users ‘Elder councils’ to participate in service planning
Examples of indicators for follow-up study http://www.julkari.fi/handle/10024/110590 “Inadequate home care “Inadequate opportunities services” among 75+ with for exercise” among 63+ care needs (% of all, men, with need for support (% of women) all, men, women)
In an ideal world (British Columbia?) Some central ‘take home’ Conceptualise care broadly and messages flexibly – not as “five minutes to prepare breakfast” Learning can be derived from both the Do not assume that care is a successes and continuum towards increasing needs failures of the Finnish and Develop training in accordance with Danish systems the orientation of care services Measure progress – using indicators that matter to recipients and providers
Kröger , Teppo and Leinonen , Anu (2012) ‘Transformation by stealth: The retargeting of References home care services in Finland’, Health and Social Care in the Community 20(3): 319-327. Rostgaard , Tine (2012) ‘Quality reforms in Danish home care – balancing between standardisation and individualisation’, Health and Social Care in the Community 20(3): 247- 254. Szebehely , Marta (2013) ‘ Marketisation in Nordic eldercare: four countries, four responses’, Presentation at the Finnish Social Policy Conference in Tampere 24 Oct. 2013 Questions and comments to: timonenv@tcd.ie – Thank you!
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