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13 th International Conference on Integrated Care, Berlin | 11-12 April 2013

13 th International Conference on Integrated Care, Berlin | 11-12 April 2013. Kai Leichsenring, Jenny Billings, Henk Nies, Susanne Kümpers Integrating long-term care in Europe – Improving policy and practice. Agenda. Introduction: The contents of the book

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13 th International Conference on Integrated Care, Berlin | 11-12 April 2013

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  1. 13th International Conference on Integrated Care, Berlin | 11-12 April 2013 Kai Leichsenring, Jenny Billings, Henk Nies, Susanne KümpersIntegrating long-term care in Europe – Improving policy and practice

  2. Agenda • Introduction: The contents of the book • Identity-building as a precondition for integrated long-term care Henk Nies, Vilans | The Netherlands • Prevention and rehabilitation and integrated long-term care Susanne Kümpers, Fulda University of Applied Sciences | Germany • Quality development across organisations and settingsKai Leichsenring, European Centre, Vienna | Austria • Improving the evidence-baseJenny Billings, University of Kent | United Kingdom • Comments from Belgian and German health policy perspectives • Jan Van Emelen, National Federation of Mutual Insurance Companies | Belgium • Christian Berringer, Ministry of Health | Germany Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  3. Background • FP7 Project “Health systems and long-term care for older people in Europe. Modelling the INTERfaces and LINKS between prevention and rehabilitation, quality of services and informal care” • Basic research on issues of “prevention and rehabilitation” at the interfaces between health and long-term care • The INTERLINKS Framework for long-term care • Themes, sub-themes and key issues • Strong focus on mainstreaming prevention and rehabilitation • http://interlinks.euro.centre.org Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  4. The final INTERLINKS Publication • Transversal issues: constructing LTC systems in Europe • Theory and practice • Policy-oriented • 15 Chapters by more than 30 authors from 13 European countries • Published by Palgrave Macmillan, March 2013 Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  5. 13th International Conference on Integrated Care, Berlin | 11-12 April 2013 Henk Nies Identity-building as a precondition for integrated long-term care

  6. Long-term care (WHO/MMF, 2000) “The system of activities undertaken by informal caregivers (family, friends and/or neighbours) and/or professionals (health and social services) to ensure that a person who is not fully capable of self-care can maintain the highest possible quality of life, according to his or her individual preferences, with the greatest possible degree of independence, autonomy, participation, personal fulfilment and human dignity” Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  7. Diversity of services to meet diversity of clients’ needs Hospital Care home Sheltered housing Sitting services Home care Mental health services Warden Informal care Family physician Housing Co-operative Health Housing r Client Alzheimer- café Supplies/ domotics Social relations Mobility Day activities Volunteers Public transport Dial-a-bus/ taxi Welfare worker Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science Meeting centres

  8. Position of long-term care in welfare systems The health-social care divide Health caresystem Social caresystem Long-term care Professional care workers Identity - Policies - Structures - Functions - Processes - Resources/Funding The formal – informal divide Users Informal carers:family, friends, volunteers ‘migrant carers’ Informal social structures Informal social structures Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  9. The Themes of a Long-Term Care System Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science Source: inspired by F.Glasl et al. (2005) Professionelle Prozessberatung. Bern et al.: Verlag Paul Haupt.

  10. Paradigms and values From: surviving to living longer to living better Values Independence Autonomy Participation Personal fulfilment Dignity Health and capacity instead of illness and impairment (LOC) Quality of life: enjoyable, meaningful, worth living for (My Home Life) In addition: freedom, security, privacy, intimacy, information and informed decisions, beliefs, rights (European Charter) Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  11. Paradigms and values Level 1 Level 2 Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  12. Paradigms and values Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  13. How to build (on) a system? Values, mission statement, define organisations Involve stakeholders in public debate and legislation (Big Care Debate) Implement mission statements that focus on LTC Define principles that are characteristic for LTC Reflect on values that shape policy, organisation and individual choices Address rights and ethics Address dignity, quality of life and empowerment in policy papersand organisational practices Include prevention and rehabilitation Embrace diversity Address interfaces (boundaries) Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  14. 13th International Conference on Integrated Care, Berlin | 11-12 April 2013 Susanne KümpersPrevention and rehabilitationwithin integrated long-term care

  15. Background & starting points • Prevention & rehabilitation – a topic within LTC? • In part scarce evidence – fragmented experience • Perspectives on P&R in LTC: • Explicit interventions (e.g. falls prevention, immunisation) • Implicit interventions:Comprehensive LTC pathway with well-integrated and high-quality care, including social and environmental aspects promoting quality of life and health Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  16. The cultural context: Ambiguities Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  17. P&R across LTC pathways • P&R potential to be developed through organisational development • As cooperation and coordination • By assuring the services needed at the right moment and place • As approach to integrated care • … and by considering a broad range of determinants of health in ‘promoting health in all policies’ such as • Contributing to age- and disability-friendly environments • Ensuring social participation Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  18. Considering the social environment:‘Quartiers Solidaires’ (Switzerland) • Background: Isolation of older people with LTC-needs • Philosophy: help vulnerable people to remain at home • Improving quality of their life – according to their stated needs • Fostering integration within the neighbourhood • Enable informal carers to deal with difficult situations • Participatory processes (‘community forums’ for older people) • ‘Reinforcing neighbourliness’ • E.g. (self-) organising regular lunch meetings • Organising meeting opportunities and joint activities • Effects: Improving individual welfare and overall quality of life Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  19. Governance: Embedding P&R … and the barriers • Embedding P&R means: To promote maintenance and rehabilitation of functioning wherever possible – in all kinds and all stages of support and care • Barriers against embedding P&R: • Long-term outcomes of P&R vs. short political timescales • Building up evidence of effects of general prevention is only partly feasible • Investing in P&R requires double funding … and people in crisis represent the stronger claim • ‘P&R’ are not unambiguous – multiple concepts and perspectives competing Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  20. The political context: Ambiguities Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science Implementingmulti-facetedpreventiveapproachestocare: a challenge

  21. Innovation at organisational level: Buurtzorg Nederland • A reaction of professionals to huge multi-layered care organisations and their bureaucratic inflexibility • Concept • Small, self-managed local teams of professionals (nurses) • Joint ICT tools • A shared general approach to assessment and care including individual and social aspects and efforts to activate patients’ resources • Effects • Professionals’ satisfaction and identity • Patients’ and their families’ quality of life and social inclusion • Cost reduction Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  22. 13th International Conference on Integrated Care, Berlin | 11-12 April 2013 Kai LeichsenringIntegrating long-term care in Europe – Improving policy and practice

  23. The quest for quality in LTC “Quality is the decent delivery of a mutually agreed service or product” (ISO 9001) Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science www.123rf.com

  24. Challenges and caveats • Defining quality in individual LTC organisations and across the care pathway • Extension of supply in the context of New Public Management • Arbitrary legislation to regulate market access, reporting and monitoring (inspections) • ‘Quality bureaucracy’ • More transparency needed: Public reporting? • Performance measurement and outcome orientation: clinical indicators vs. quality of life • Lack of knowledge and training Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  25. Improving quality assurance and quality management in LTC • Shared views • Institution-building • guidance, training, research • Legislation • Appropriate quality management systems at organisational level • involvement of relevant stakeholders • Enabling professionals • training • Involving users and carers Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  26. Trends • From inspection to self-assessment and third-party certification • From quality assurance to continuous improvement • guidance, training, research • First steps towards quality assurance and quality management across boundaries Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  27. Promoting quality management in linking, coordinating and integrating health and social care • Integration at area level • new types of cooperation in the neighbourhood • Integration in care pathways • beyond disease management (focus on prevention and rehabilitation) • Integration at professional level • inter-professional training • Integration of funding levels • integrated commissioning? Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  28. Practice example:Quality management of integrated stroke services(The Netherlands) • New pathways, performance indicators and criteria for effective stroke services • acute period, rehabilitation, chronic care, patient satisfaction • Improved patient-satisfaction • ‘Stroke-chain coordinator’ • networking, monitoring, evaluation • Challenges: • new interfaces • multi-morbidity • specialised vs. holistic approaches Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science Source: Diermanse, 2011

  29. 13th International Conference on Integrated Care, Berlin | 11-12 April 2013 Jenny BillingsThe Search for Evidence in Long-Term Care

  30. Our starting point – debates on evidence A hierarchical view of knowledge and evidence:Randomised Controlled Trials or nothing Decisions about complex health and social care issues need multiple approaches to getting evidence (Glasby and Beresford, 2006) Call for pluralistic methods Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  31. What evidence do we have on LTC? • Benefits for whom and in what context? • Many ‘successful’ experiments fail to transfer to much larger populations • Search for the benefits of integrated care … • What and how do we measure? • Problems of design, intervention, measure Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  32. Evidence collected in the INTERLINKS template What are/were the effects? • Evaluation methods, assessment of benefits and effects for older people and carers, addressing gaps and improving interfaces What are the strengths and limitations? • Strengths, weaknesses, opportunities and threats, intended or non-intended effects. Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  33. Analysis of the ‘evidence base’ of INTERLINKS practice examples (n=59) Category 1 (n=7) • pluralist mixed method evaluation , results contributed towards the evidence-base, some generlisability • Eg the PALKO model (Finland) Category 2 (n=17) • strong element of evaluation, where evidence was generalisable or could be used for local improvement Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science • Eg Equinoxe – national home alarm system (France)

  34. Analysis of the ‘evidence base’ of INTERLINKS practice examples Category 3 (n=4) • initiatives to develop and implement assessment tools, to add to the evidence base or improve LTC practice • Eg E-Qalin quality management system (EU) Category 4 (n=31) • minimal, incomplete or no evaluation, but the project had been rolled out or was on-going Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science • Eg Needs assessment model (Slovakia)

  35. The PALKO Model to improveinterdisciplinary working (Finland) • Experimental with pluralist approaches • cluster randomised trial with municipalities (n=22) • documentary analysis of records registers • questionnaires measuring satisfaction and quality client interviews at discharge, 3 weeks, 6 months • Results • Clients used service less, decreased costs, reduction in overlapping work Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science • Process improved, no extra resources needed • Applicable to different client groups in different settings and organisations

  36. The way forward.... • In LTC, evidence still reliant upon more ‘informal’ sources • Interventions becoming more complex: • Pluralistapproaches needed but sophisticated in design with a robust evaluation framework • High quality evaluation becoming ‘an expensive luxury’ • Need for in-built evaluation methods, service investment from the onset Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  37. Discussion Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037 Co-funded by the Austrian Ministry of Science

  38. Contact: • Kai LeichsenringEuropean Centre for Social Welfare Policy and Researchleichsenring@euro.centre.org Further information: • http://interlinks.euro.centre.org Funded by the European Commission under the Seventh Framework Programme Grant agreement no. 223037

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