Creating integrated person-centred care in different settings

Norwegian and Danish municipalities are in the process of strengthening their health- and social care systems to encourage elderly people to live in their own homes for as long as possible. Their aim is a service apparatus characterized by integrated person-centred care. The Context project has examined how the implementation of this ideal is influenced by national and local contexts. The project was based on a "layered case study” design." A Danish/Norwegian research team conducted collective, short-term fieldwork in Danish and Norwegian municipalities, shadowed various professionals in their daily work, interviewed leaders, employees, and users from different services, thereby gaining a "up-close" insight into how the service ideal is translated into practice. In addition, we utilized local and national policy documents, existing statistics, and data from NORDCARE, a Nordic survey conducted in 2005 (N=5,000) and 2015 (N=8,000). Policy documents and strategies from the two countries contain similar ideas about trust-based management, interdisciplinary teamwork, user involvement, and reablement. The way in which these ideas were translated into practice was partly influenced by different national reform paths, governance traditions, professional profiles, and cost-saving strategies. For example, in Denmark, reablement was understood as an activating intervention offered within the regular home care service and integrated with efforts to reduce the extent of practical assistance. In Norway, reablement was associated with the Coordination Reform and was thus a part of municipalities' ambitions to prevent costly (re)admissions to hospitals. Both countries face common challenges as well. For example, an optimistic belief that team organization will promote interdisciplinary collaboration proves difficult in practice. Fully integrated teams may work where employees from different professions work with the same users (as in HVR teams) but poses significant challenges when the user group is heterogeneous, i.e., where some users require intra-professional and others inter-professional attention. Clarifying who should confer with whom about what, when, and how increases the demand for coordination. In "self-directed" coordination resources to handle this complexity may be insufficient. Contemporary home care services are complex and require considerable coordination work. Since patients often have unstable and changing needs, and staffs work rotating shifts, work schedules must be constantly adjusted. The demands for leadership and coordination increase with high sickness absence, high turnover, and the use of part-time staff and substitutes who take shifts at various workplaces. The NORDCARE survey reveal that Norwegian care workers, unlike their Danish counterparts, often work in small part-time positions and experience great unpredictability in their daily lives. A part-time system consisting of small positions where professionals work at multiple workplaces is a structural feature of Norwegian elderly care that hinders the realization of the ideal of integrated and person-centred care provision. In both countries, the knowledge base of physiotherapy and occupational therapy have gained a central place in elderly care, not only through new service offerings like reablement, but also by shaping the general discourse on what constitutes good elderly care. Facilitating active and independent lives for the elderly often equates to working purposefully to improve the physical functional abilities of older people. Care work is thus made visible based on a “logic of training”. Employees are encouraged to measure and document progress and to demonstrate that they succeed in keeping the level of assistance low. This logic makes sense for the elderly who have lived an active life before a functional decline, but it poses challenges when the elderly person is lonely or does not feel they have the potential to improve their functional level. Our field observations reveal how therapists and caregivers exceed work plans to tailor the service to individual people and situations. While the official discourse is based on a polarized understanding depicting traditional care as passivating reablement as activating, we present a more nuanced picture: Regular home care services can be activating in the sense of maintaining the elderly's zest for life. Stories from the elderly suggest that even tiny drops of social care can provide psycho-social stimulation and contribute to a sense of belonging to the outside world. However, since social care is invisible, it is not supported on par with physical and functional training. Analysis based on NORDCARE suggest that care staff feel that their work is not valued at a societal level. Many are considering quitting their jobs. Future research should further investigate whether the experience of having a valued job can be stimulated by emphasizing the significance of the social care they offer

Hensikten med prosjektet har vært å framskaffe kunnskap om hvordan nye tjenesteidealer om integrerte og personsentrerte tjenester formes og iverksettes i norske og danske kommuner. Vi har vært særlig opptatt av å belyse hvordan kontekstuelle betingelser kan tenkes å prege oversettelser fra ide til praksis. Vi har vist hvordan iverksetting av ideene har blitt preget av de to landenes ulike styringstradisjoner, ulike profesjons- og tjenesteprofiler, ansettelsesformer og organisering av skiftarbeid. Vi har også vist hvordan iverksettingen er preget av lokale prioriteringer og lokale organisasjons og ledelsesformer. De komparative analysene har vært relevante og nyttig for norske praktikere og beslutningstakere fordi den bidrar til å klargjøre (a) hvilke danske erfaringer som er relevante og irrelevante for en norsk kontekst og (b) hvilke forutsetninger som kreves for å realisere tjenesteidealene. Vi har erfart at kunnskapen gir direkte innspill til kommunenes arbeid med å iverksette tillitsreformer og tilrettelegge for bærekraftig bemanning og kompetanseutvikling i tjenestene. Prosjektet hadde i utgangspunktet en ambisjon om å prøve ut nye samarbeidsformer mellom forskere og praktikere, dels gjennom å invitere praktikere til å delta i feltarbeider, dels gjennom å arrangere refleksjonsgrupper omkring data-analyser. Selv om ikke observasjonene lot seg gjennomføre like konsekvent som planlagt erfarte vi at både forskere og praktikere hadde nytte å reflektere sammen omkring dansk/norske kontraster og erfaringsnære dilemmaer i feltet. Analysene har nådd bredere ut enn bare til de involverte kommune. Resultater fra prosjektet har vært formidlet til praksisfeltet gjennom kronikker, konferanser og undervisningsopplegg, inkludert deltidsstudier som tilbyr videreutdanning for kommunale ledere og en rekke profesjonsutdanninger innen helse- og omsorgsfeltet. Vi vil også nevne at analyser basert på NORDCARE-data har vært anvendt både i sysselsettingsutvalgets (NOU 2021: 2) og helsepersonellkommisjonens utredning (NOU 2023:4) arbeider. I tillegg fikk analysene en betydelig plass i et kapitlene i en rapport fra OECD (2023) Beyond Applause? Improving Working Conditions in Long-Term Care, som omhandler bemanningskrisen og arbeidsforholdene som ble avslørt i mange lands eldreomsorg i kjøvannet av Covid 19. Via disse kanalene mener vi at prosjektet har bidratt med å opplyse samfunnsaktuelle debatter. Prosjektet har bidratt til å opprettholde kontakten med et nordisk forskningsmiljø. Vi har i tillegg til det tette samarbeidet innad i prosjektet arrangert og deltatt i flere webinar og seminar på nordisk plan. Ikke minst har det nordiske perspektivet blitt videreført gjennom den kompetanseutvikling stipendiater og yngre forskere har oppnådd gjennom prosjektet. Prosjektet har også stimulert til nye prosjekter og forskernettverk.

The movement towards integrated person-centred care has shown some positive effects, research indicates however that outcomes are highly context-specific. Success depends for instance on whether care organizations are able to influence the mindset of the staff, use economic incentives effectively, and modify the way work is organized. The implication, motivating this project, is that new research should address how settings and contexts which enhance people-centred care can be created. A mixed-method design is utilized. Qualitative analysis of care systems is integrated with quantitative analyses of survey data. The major part of the project consists of case studies of six local care systems which differ in national contexts (four Norwegian, two Danish study sites), type of community (urban/rural), and administrative style (more or less inspired by New Public Management). The overall issue is why interventions aiming at integrated person-centred care succeed in some settings, but fail in others. The analyses will explore initiatives aiming at a) making older people more self-reliant (e.g., home care reablement); b) improving integration between health services and elderly care; c) making staff-client relations more collaborative; and d) establishing collaborations between the care organization and local volunteers. Contextual preconditions for successful outcomes, in terms of aspects both of the care organizations and the surrounding environments, will be identified. The main technique of the case studies is a site switching approach drawing on the skills of a multi-disciplinary research team of academics and practitioners. Qualitative data from case studies will be linked to statistical analyses of a large Nordic survey among staff in elderly care conducted in 2005 (N=5,000) and 2015 (N=8,000). Survey findings will assist in determining how typical are the case-study work organizations, while the case studies will enhance interpretations of survey findings.