care: International forum THE FINNISH AND DANISH CASES B Y P R O F - - PowerPoint PPT Presentation

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

Best practices in seniors’ home care: International forum

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
• rganised, 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)

Denmark

Denmark

• Strong orientation to home care

(3/4 of expenditure)

• Large share of older population in

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

Finland

Avustaa lukemisessa; Kirjoittaa yhdessä kirjeitä Avustaa vaatteiden valinnassa; Pitää huolta kodin kasveista Pelata kortti- ja muita pelejä; Koristella kotia esim. juhliin Järjestää ja säilyttää reseptit; Valmistella kauppalistat Valvoa ja opastaa TV:n käyttöä Opastaa tietokoneenkäyttöä Postittaa kirjeet ja asiakirjat Ostaa kirjoja, aikakaus- ja sanomalehtiä Suunnitella vierailuja, ulkoiluja ja matkoja Vierailla naapurien ja ystävien luona Ylläpitää valokuva-albumeita; Arkistoida perhehistoriaa

• Growing diversity of providers,

fuelled by outsourcing (of all purchases costing ≥100 K) and tax credits that incentivise direct purchase of services, especially by the better-off

• Less strongly oriented to home care

than Denmark (about 50:50 home and institutional care)

• Entitlement more finely graded;

user fees apply based on income and usage

• Attempts to integrate family care

into the formal care system

• Intensification: greater fusion of

health and social care

(Kröger and Leinonen 2012)

Source: Szebehely 2013

Key differences

Role of family and markets stronger in Finland than in Denmark

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
• f 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

And attempts to do better…2013 Danish home care commission report

Key emphases / recommendations:

 % of older people in receipt of home care has

declined – older adults a more diverse group

 …partly thanks to hjælp-til-selvhjælp (‘help to

help oneself’)

 Call for more evidence on the effects of

rehabilitation; financial incentives for providers

 Better use of IT applications  Age limit of preventive visits raised to 80

Recommendation 7

Recommendation 14

“The Commission recommends that the target group for rehabilitation includes both individuals who may benefit from a time-limited rehabilitation, as well as people with very complex needs who may benefit from long-term support with a rehabilitative purpose.” “The Commission recommends that municipalities restrict the detailed management of time and individual services in order to provide greater flexibility and more room for professionalism in the encounter between a citizen and employee.”

Key recommendations

…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 services” among 75+ with care needs (% of all, men, women) “Inadequate opportunities for exercise” among 63+ with need for support (% of all, men, women)

Some central ‘take home’ messages

Learning can be derived from both the successes and failures

• f the Finnish and

Danish systems

In an ideal world (British Columbia?)

• Conceptualise care broadly and

flexibly – not as “five minutes to prepare breakfast”

• Do not assume that care is a

continuum towards increasing needs

• Develop training in accordance with

the orientation of care services

• Measure progress – using indicators

that matter to recipients and providers

References

Kröger, Teppo and Leinonen, Anu (2012) ‘Transformation by stealth: The retargeting of 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!