Providing integrated health care for older people

The broad theme of this study is the preconditions and consequences of integration and co-operation across professions and institutions within the health care sector and between sectors at the local level. We have conducted in- depth studies of recruitment policies and the division of labour in elderly care in seven Norwegian municipalities. The study is based on document analysis of policy documents, plans and reports as well as interviews with civil servants, representatives from professional associations, care service managers and employees in home care and nursing homes, patients and their involved relatives. Family members' contribution to elderly care is becoming increasingly important in the Western world. To better utilise family carers as a resource in elderly care we need to increase our understanding of their role. However, there is a lack of in depth research on the role of family carers. In our study we find that family carers fill this role in many different ways according to their resources and relationship with the older person. Further, we note that family care can be experienced as straining, but also as meaningful. We find that family care is seen as meaningful because it can make a difference to the old person's well-being and health, it is linked to intergenerational reciprocity and it is socially rewarding. Our study suggests that it is important that family carers are allowed to choose how to help according to their resources and capacities. It also seems to be vital that family carers' effort is explicitly appreciated by professional care workers and others. We also explore a particular tool related to the management of care work, namely individual care descriptions (ICDs). ICDs may be seen as neutral tools for professional carers. In public reports, however, ICDs are often described as management tools for coordination, intended for the provision of increased efficiency, accountability and user involvement in the public sector. The management of care work practices are investigated from the perspectives of care workers in four different care settings. The analysis uncovers that although ICDs may coordinate and standardise practices, they may also work very differently in different settings. Grounded empirical investigations are therefore crucial in order to understand how ICDs work. We have studied how managers and employees in the case municipalities report that the pressure on services have increased during the last few years, and many of the interviewees relate the situation to the National Cooperation reform of 2012. Some of our informants have experienced sudden changes in tasks, while others report that the reform reinforced long- term development. Nursing home managers and staff experience an increased pressure on short- term beds because more patients now are transferred directly from hospitals. In home care services, tasks have grown and become more complicated as patients increasingly are transferred also directly home after hospital treatment. The threshold for getting a nursery home bed has risen, and more ill elderly now receive care and treatment in their homes. In both services, staff increasingly carrie out complex care and treatment, and this leads to changes in demand for competent staff. The municipalities have systematized their planning for competence development, recruitment and division of labor to a varying degree, and the local competence and capacity for such planning varies. We found that the service managers of both nursing homes and home care services aim at strengthening the competence by attempts to recruit traditional health care and medical staff. Both in home care and in nursing homes, the main strategy for coping with new and complex tasks is to attract skilled nurses, special nurses, physicians and even specialized physicians. Due to lack of sufficient educated professionals in some of the municipalities, education of existing staff is the preferred measure to cope with increasing and more demanding tasks. Services in all municipalities seem dependent upon delegation of tasks, in particular from nurses to nurse assistants and unskilled assistants. In many cases the services seem dependent upon assistants carrying out tasks like medication in weekends and at night. In some cases this is used randomly as a solution of immediate lack of skilled staff, leading to worries among nurses regarding the quality of services and the responsibility if something goes wrong, but delegation can also be part of a planned scheme, with more systematic training and control.

The broad theme of this study is the preconditions and consequences of integration and co-operation across professions and institutions within the health care sector and between sectors at the local level. Our focus is on older people and we have chosen c are pathways regarding treatment and rehabilitation of hip fractures as our empirical case. Within this framework we have prepared a multidisciplinary project, involving research institutions across several countries, which will study treatment, rehabilit ation and preventive measures. The project is organised in four modules. In module 1 we explore the institutional framework for integrated health care through studies of the new contracts regarding co-operation between hospitals and municipalities. In m odule 2 we investigate altered professional roles, co-operation across professions and across local departments in a Norwegian perspective and in an international perspective (2A+B). Module 3 focuses on the clinical pathways and the clinical outcomes of i ntegrated care, and module 4 is dedicated to the perspectives and experiences of the users (older patients and their relatives) and their interactions with the health care system. We will base our analyses on register data, surveys, document analyses an d interviews. The project will provide new knowledge on co-ordination and co-operation between the different levels of health and care services and between the older patients, their families and the local community.