Kai Leichsenring European Centre for Social Welfare Policy and Research Vienna | Austria

1. First Congress of Care Models and RehabilitationTourism for Older People 21-23 November 2012 | Izmir (Turkey) European perspectives on integratinghealthandsocialcareTowardsintegrated long-term care systems Kai Leichsenring European Centrefor Social Welfare Policy and Research Vienna | Austria

2. Evidencing systemic deficiencies:The phenomenon of migrant carers • Italy: over 700,000 ‘badanti’ • Live-in personal assistants, often without any training • High number of moonlighting • Partly legalised • Austria: over 30,000 ‘24-hours assistants’ • Legalised in 2007 • Similar situation in Germany, Greece, Spain … • A (partly legalised) phenomenon with a close expiry date? • A clear sign for distortions in the way we conceive and deliver long-term care

3. Reacting to systemic deficiencies:Innovation by professionals “Buurtzorg” (The Netherlands): More autonomy, less cost • 2006: Unsatisfied community nurses found a multi-professional organisation • Care in the community (neighbourhood): Users at the centre • Autonomous, multi-professional teams of max. 12 professionals • Networking with local, formal and informal resources • Quality management and transparent outcome indicators: very high user satisfaction • Organisational costs as low as possible, partially by using ICT: cost decreased up to 50% • Promoting activation and self-care in the neighbourhood • Staff grew from 2007-2011 from one team of 12 to 4,000 professionals • Netherlands’ Employer of the Year 2011 Quelle: de Blok, 2011; htttp://interlinks.euro.centre.org

4. Terminology Towards an integrated system of long-term care The health-social care divide Socialcaresystem Healthcaresystem Long-term care linked-in, co-ordinated, integrated? Services Residential care Providers Professions Methods Legal Framework Policies Hospitals - Services Providers - Professions GPs - Methods Legal Framework Policies Identity - Policies - Structures - Functions - Processes - Resources/Funding Users The formal – informal divide Informal carers:family, friends… ‘migrant carers’

5. 22 November 2012 | First Congress of Care Models| Izmir Aims Aims of the presentation • To present key-issues of joint working and integrated care resulting from the FP7 Project INTERLINKS - Health Systems and LTC for older people in Europe • The INTERLINKS Framework for LTC: Modelling the interfaces and linksbetweenprevention, rehabilitation, quality of services and informal care • To illustrate the framework by innovative practiceexamples • To inspire your own approach to integrating health and social care

6. 22 November 2012 | First Congress of Care Models| Izmir Products Results • A European Framework for LTC • 6 themes, 29 sub-themes and 135 key-issues • illustrated by about 100 validated practice examples • An interactive website  http://interlinks.euro.centre.org • to facilitate analysis and comparison • to involve users in providing feedback and their own practice examples • Country information: 33 National reports • 4 European overview reports on prevention & rehabilitation, quality management, informal care, governance & finance of LTC …

7. Terminology http://interlinks.euro.centre.org The story ofMrsL.T. Care

8. Modelling 22 November 2012 | First Congress of Care Models| Izmir The Themes of a Long-Term Care System Source: inspired by F.Glasl et al. (2005)

9. Modelling Describing and analysing individual themes 6 • Themes 28 • 3-6 subthemes in each theme 135 • 2-8 key issues for each subtheme • About 100 practice examples to illustrate key-issues

10. Key-issues 22 November 2012 | First Congress of Care Models| Izmir Selected key-issues in integrating health and social care services • Values and mission statements that address the interfaces with health and social care services, and with informal carers • Initiatives to promote prevention and rehabilitation, qualitydevelopment and empowerment of users • Fostering a culture of collaboration, inter-professional exchangeand transfer of information

11. Key-issues 22 November 2012 | First Congress of Care Models| Izmir Selected key-issues in integrating health and social care services • Establish leadership competencies regarding the management of networks • Shaping (new) job profiles, fostering and mutual understanding of comprehensive pathways • Using contracts or agreements to enable and sustain processes between services and/or organisations • Facilitate individual and multi-professional care planning

12. Key-issues 22 November 2012 | First Congress of Care Models| Izmir Practices of integration and coordinationat the individuallevel • Case management • Case managers for people with dementia and theirinformalcaregivers • Multi-disciplinaryteams • Family Doctors contracted as staff members in care homes • Personalisation • Overcoming the ‘safety trap’ with IT applications and joint working

13. Key-issues Practices of integration and coordination at the organisational level • Inter-professional agreements about care pathways • Integrated home care and discharge practice for home care clients (PALKOmodel) • Team work integrating health and social care staff (new job profiles) • Implementation of everydayassistance in institutionaldementiacare • Integrated discharge and follow-up planning • Integrated care in a Hospital with Polyclinic • Quality management • Multidisciplinary assessment and improvement of quality in care homes

14. Key-issues 22 November 2012 | First Congress of Care Models| Izmir Facilitating integration and coordination at the systems level • Opportunities in terms of linking social and health care • Reimbursement (fines) for delayed hospital discharges • Enabling joint conversion processes • Organising alternatives to nursing homes • Realisingintegrated care in the community • Bridgingthe gap between nursing home and community care

15. Practice Examples Case managers for people with dementia and their informal carers (The Netherlands) • Aim: • Enhancing user orientation and co-operation in community dementia care by multidisciplinary teams consisting of case managers, geriatricians, a psychologist and a dementia consultant, funded via diagnosis treatment combinations • Effects: • Positive effect on clients’ mental health, general health and vitality • Decrease of informal caregivers’ burden • The approach can be used in care homes and at home ⏏ Source: http://interlinks.euro.centre.org/model/example/CaseManagersForPeopleWithDementiaAndTheirInformalCaregivers

16. Practice Examples Family Doctors contracted as staff members in care homes (Germany) • Point of departure: • Care home providers received a fixed budget from the health insurance to ensure medical care for the insured residents • Effects: • Better medical care, more cooperation, less prescriptions • Higher satisfaction of residents and economic savings • Limitations: • Undersupply of specialist care and general lack of medical staff • Few Family Doctors are geriatricians (see NL: Care Home Physicians) • Financial disincentives and competition between health insurances • Further medicalisation of long-term care? ⏏ Source: http://interlinks.euro.centre.org/

17. Practice Examples Safe monitoring of people sufferingfrom Alzheimer’s disease (France) • Aim: • reducing the risks of ‘Alzheimer’s wandering’ • Means: • GPS/GPRS localisation system (bracelet) with defined ‘safe’ area • Passive alarm if moving off the defined area • Active alarm if person feels lost • Call centre will get in touch with one of three contact persons to check • Cost: about €70 for a 3-month period • Can be used in care homes and at home ⏏ Source: http://interlinks.euro.centre.org/

18. PracticeExamples The PALKO Model to improveinterdisciplinaryworking (Finland) • Standardised practices and agreements between hospitaland home care to define practices, responsibilities and support tools • Accompanying the client’s whole pathway: home – hospital – home • A care/case manager pair for each home care client • Multidisciplinary team work moving away from a reactive to a proactive way of working • Tested by an experimental study design • Process improved, no extra resources needed • Applicable to different client groups in different settings and organisations ⏏ Source: http://interlinks.euro.centre.org/

19. PracticeExamples Implementation of everyday life assistance in institutional dementia care(Germany) • The German Long-term Care Development Act of 2008 introduced several new options for better financed and organised dementia care • Everyday life companions get a training of 1,000-hour of theoretical and practical training over a period of about 7 months (+ 400 hours internship) • They work ‘between care and therapy’ in an area where no other care professional is responsible: to structure and shape the everyday lives of older people with dementia • Still no standardised qualification programme and certification • De- or re-professionalisation? ⏏ Source: http://interlinks.euro.centre.org/

20. Practice Examples Integratedcare in a Hospital withPolyclinic(SlovakRepublic) • Two settings under one administrative umbrella • General hospital with polyclinic: health legislation • Care home HUMAN: Social Services Act • Shared resources and capacities • Intermediate and long-term care for older people: individual care planning • Pertaining problems: • restricted capacity (13 places) • Poor links to not sufficient residential and/or community care ⏏ Source: http://interlinks.euro.centre.org/

21. Practice Examples The E-Qalin Quality Management System (AT, SI, DE, LU …) • Training of E-Qalinprocessmanagers • Inter-disciplinary self-assessmentprocesswith 66 criteria in the area of ‘structures & processes', and 25 foci in the area of ‘results’ • Involvement of residents and other relevant stakeholders • Basis for ‘National Quality Certificate’ (external audit) • Voluntary approach based on partnership between regulators and providers • Future perspective: benchmarking and improvement by learning organisations ⏏ Source: http://interlinks.euro.centre.org/

22. Practice Examples Reimbursement(fines) for delayedhospital discharges (Sweden) • Aim: To reduce ‘bed-blockers’ in hospitals • Reform: Municipalities (responsible for community care and housing) have to reimburse Counties (responsible for hospitals) if patients cannot be discharged due to the lack of local services and arrangements • Methods: joint care planning • Results: Decrease of ‘bed-blockers’ between 1992 and 1999 from 2,500 to about 1,000 • Now stable at about 1,100, but other factors are also important: • Availability of alternative residential and other forms of care • Availability of local resources • Partnership approach, rather than ‘passing the buck’ ⏏ Source: http://interlinks.euro.centre.org/

23. Practice Examples Organisingalternatives to nursinghomes (Birmingham – UK) • Commitment by City Council to moderniseolderpeople’sservicesfor a new generation of olderpeople • New ‘special care centres’, extra care housing and independentsectorhomes • Closure of existingCouncilday centres and care homes • Older people and their families felt unsettled and distressed during the closures, butoutcome data after 12 months suggest positive results: • Majority felt valued and happy with the control they had over their life at all stages of the study • 42% said life had got better, 35% said it had stayed the same (even though they were a year older and frailer) • Of the 19% who suggested life had got worse following changes, around half of these respondents said this was due to declining health not the closures ⏏ Source: http://interlinks.euro.centre.org/

24. Practice Examples The Skævinge Project (Denmark) • Commitment by Municipality to turn the care homeinto a public health centre (back in 1984!) • Organisational development and preventive, self-care approach • 24-hours care services also delivered in the community • Increased health outcomes, lower unit-costs • Possibility to use economies for the development of new types of services (dementia care unit, day-care etc.) • Triggered national Danish legislation to stop building traditional care homes ⏏ Source: http://interlinks.euro.centre.org/

25. Conclusions Conclusions: Successful examples create win-win situations by linking and networking! • Promote networking and multi-professional training • Finding, educating and retaining appropriate staff will be the most important challenge during the next decade – new job profiles, active outreach and cooperation between stakeholders are needed! • Produce evidence for successful solutions • Develop and present your performance by showing evidence, by working in partnership and by transparency towards users! • Think systemic and act locally • Facilitate mutual exchange and reflection for improving integrated care pathways and identifying all local resources!

26. More information and contact • Kai Leichsenring, Jenny Billings and HenkNies (eds.) (2013)Long-term care in Europe – Improving policy and practice. Basingstoke: PalgraveMacmillan. • http://interlinks.euro.centre.org • leichsenring@euro.centre.org • www.euro.centre.org