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HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester

Creating integrated person-centred care in different settings

Alternative title: Om å skape integrerte, personsentrerte omsorgstjenester i ulike kontekster (kontekst-prosjektet)

Awarded: NOK 13.8 mill.

Nordic governments call for health and social care provision to be more proactive and preventative. They argue that interdisciplinary expertise should be better utilized and services should attend more adequately to the uniqueness and agency of individuals. In this research project (CONTEXT) we aim to explore how these new service ideals are translated and put into practice in different national ( Norwegian and Danish) and local (rural and urban) contexts. Based on comparative case studies from Norwegian and Danish municipalities we combine multiple techniques for eliciting data, for instance rapid site switching ethnography whereby a team of 10-12 researchers shadow professional care staff and make interviews with leaders, staff and service users at different levels and arenas of the local community care system. Particular attention is paid to horizontal coordination within and between various municipal service providers as well as with adjacent service providers (such as hospitals and voluntary organizations). We also focus attention on preconditions for providing person centered care. Adding to the case studies we analyze data from a Nordic survey among staff in elderly care (the NORDCARE survey) conducted in 2005 (N=5,000) and 2015 (N=8,000) has been analyzed. Local governments in all four municipalities aim at creating integrated person-centered care. However, these identical policy ideas are translated differently into practice as they adapt to different contextual conditions, such as different national legislation and policy measures, different established governance models and different traditions regarding work organization, skill-mixes and work-time arrangements. Although our case municipalities highlight the value of integration and interprofessional collaboration, new tasks delegated from the hospital sector imply that services are split up and organized as specialized services for specific patient groups, such as patients with severe medical needs, dementia or a potential for rehabilitation. Our municipalities navigate differently to realign the need for specialization and more coherent care. We find that specialization tend to imply a prestige hierarchy. Working with patients in certain stages of an illness trajectory (rehabilitation, palliative care) tend to attract more qualified staff and thus provide more beneficial conditions for care than working with frail elderly in need of regular nursing care. The new complex structure have created new problems relating to service allocation and rationing. We find that collaborating across different disciplines may enhances the learning environments in some settings. However, we also disclose that if interprofessional collaboration is regarded an aim in itself it may displace the benefits of creating strong mono-disciplinary environments thus contribute to professional dilution. Active ageing is a core aim in the local policy of all four municipalities and is evident both in the care ideology of home care and daycare services. Drawing on ethnographic data, we explore the lived consequences of these policies. We find that day care is increasingly target towards the frailest elderly who are at risk of being passivated. Attendees of these day-care centers value the visits to the centers highly. The social gathering provides physical and mental stimulation and creates a daily rhythm and break from a boring life in their own home. However, we observe a certain tension between spontaneous socialization and profession-driven activation work. Leaders, professionals and lower skilled staff value the principles of person-centered care. It make sense for them to focus on the needs of single individuals rather than on the needs of the service. Preconditions for successful outcomes may however be undermined by lack of staff, work pressure and lack of relational continuity. Our analysis based on the NORDCARE-survey indicate that the problem of relational continuity is particularly urgent in Norway because of a high number of employees working in small part-time position in combination with rotating shift schemes. In Denmark the level of full-time and large part-time positions is higher and involuntary part-time almost non-existence. Practical nurses normally work fixed shifts. Nordcare data reveal that a large share of vocationally skilled care workers in both countries have seriously considered to quit their job. Although the majority of respondents experience that clients and their families recognized their work, very few of them experience that politicians, officials and the mass media do so. Our analysis indicate that lack of recognition at the societal level heightens turnover consideration among care workers.

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.

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HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester