Transformation by stealth: the retargeting of home care services in Finland

This paper analyses the trends and changes that home care services for older people have undergone during the last two decades in Finland. The data used come from national social care statistics, covering the time period from 1990-2010. The results show that, in contrast to many other European nations that have expanded their home care provisions, the coverage levels in Finland have dropped dramatically during this period. Those with the highest needs do receive increased amounts of support, but others have become excluded from publicly funded home care provisions and often need to rely on family members. In most localities, public service provision is focused on personal care, and no longer covers household tasks. This major change of the character of the service is connected to three other recent trends that structure current provisions: the amalgamation of home-based social and healthcare services, the marketisation and emerging privatisation of care and the integration of informal family care into the formal care system. Overall, the changes represent weakening defamilisation, that is, decreasing public responsibility for the needs of many older people and, correspondingly, an increasing reliance on family carers. This full-scale transformation of home care has taken place without any real policy debate or major modification of legislation. No actual decision was ever made to thoroughly alter the character of home care in Finland: the transformation happened by stealth.     

Nursing home social worker skills and end-of-life planning

Little empirical information exists on nursing home social worker's involvement in advance care planning and end-of-life decision- making with nursing home residents and their family members. The purpose of this exploratory study was twofold: (1) to identify the frequency of skills associated with advance care planning that social workers use, and (2) to explore the factor structure of the scale used in the study. Results from 138 nursing home social worker respondents from New York State showed high frequency of advance directive discussions, care planning, and conflict resolution with families. The instrument factors clustered around administrative duties, and grief issues. There was substantial interest in continuing education in grief counseling with families.     

Role divergence and complexity in gerontological home care.

This study documents high levels of role complexity and functional overlap in the field of home health care. Personnel perform a wide range of "professional/organizational" and "community/familial" service functions though the emphasis is on the delivery of a battery of pseudo family-like tasks. The importance of a familial orientation does not significantly decline when controlling for length of employment or organizational rationality. Role orientation is, however, significantly associated with a worker's chronological age. Results lead to program planning recommendations meant to influence staff training paradigms in home health care.     

Assessing the residential care needs of nursing home applicants

In a study of nursing home applicants, residential care decisions made by a multidisciplinary assessment team were examined. The team agreed that of the 296 applicants assessed, 54 per cent required the high level of physical and supportive care provided in a nursing home. Hostel care was recommended for 17 per cent, continuing care at home for 17 per cent, hospice care for 1 subject, and in 13 per cent of cases the team postponed their decision. A decision for nursing home care was associated with low Barthel Index of Activities of Daily Living scores, dementia, incontinence and the absence of a carer willing to continue care. A decision to delay was associated, in most cases, with a requirement for further in-patient assessment and/or rehabilitation, and therefore with a potential for functional improvement. A decision for hostel care instead of home care was associated with a low level of informal support and the absence of a carer who was a spouse or daughter. The findings suggest that a program of geriatric assessment will accurately identify the differing care needs of nursing home applicants. The initial value of such an assessment program may be to contribute to the planning of residential and other long-term care services rather than to reduce inappropriate nursing home admissions.     

Possibilities and problems in the development of home care technology.

Limited resources for health care and increasing health care costs have led to proposals to expand home care services. Presently, home care technology is rather primitive. Its development and use have been largely unplanned. Nonetheless, home care technology is growing in response to obvious needs, and a number of experiments in the Netherlands have begun to demonstrate some potentials in this area. As technological developments accelerate, opportunities for supporting people in their homes will greatly increase. The major problem with the introduction of technology into home care is the lack of an integrated home care system that can select, provide, and assess technology. Without such a system, industrial developments in this area will probably continue to be slow.     

‘It ain't what you do it's the way that you do it’: lessons for health care from decommissioning of older people's services

Public sector organisations are facing one of the most difficult financial periods in history and local decision‐makers are tasked with making tough rationing decisions. Withdrawing or limiting services is an emotive and complex task and something the National Health Service has always found difficult. Over time, local authorities have gained significant experience in the closure of care homes – an equally complex and controversial issue. Drawing on local knowledge and best practice examples, this article highlights lessons and themes identified by those decommissioning care home services. We believe that such lessons are relevant to those making disinvestment decisions across public sector services, including health‐care. The study employed semi‐structured interviews with 12 Directors of Adult Social Services who had been highlighted nationally as having extensive experience of home closures. Interviews were conducted over a 2‐week period in March 2011. Results from the study found that having local policy guidance that is perceived as fair and reasonable was advocated by those involved in home closures. Many local policies had evolved over time and had often been developed following experiences of home closures (both good and bad). Decisions to close care home services require a combination of strong leadership, clear strategic goals, a fair decision‐making process, strong evidence of the need for change and good communication, alongside wider stakeholder engagement and support. The current financial challenge means that public sector organisations need to make tough choices on investment and disinvestment decisions. Any such decisions need to be influenced by what we know constitutes best practice. Sharing lessons and experiences within and between sectors could well inform and develop decision‐making practices.     

我国企业女职工保健政策法规执行情况分析

目的:了解我国女职工保健相关政策法规贯彻执行情况,为进一步完善女职工保健法律法规提供科学依据,促进企业对女职工保健工作的重视。方法:选取我国东、中、西部的福建省福州市、北京市海淀区、甘肃省兰州市作为本研究的现场。抽取研究现场存在职业危害因素的部分企业,共482家,进行调查研究。结果:各种类型的企业间女职工保健相关政策法规执行情况存在差异,独资企业执行情况明显好于其它类型的企业,民营/私营企业的执行情况较差。结论:目前我国女职工保健工作执行状况还存在许多问题,有待于进一步完善。     

The effects of economic reform on health insurance and the financial burden for urban workers in China.

Since 1980, Chinese enterprises have been undergoing reforms in employment practice, taxation, and workers' health/welfare benefits coverage. In particular, Chinese businesses have been facing a major challenge with respect to the financial burden of providing medical benefits to their workers. The purpose of this paper is to analyse the impact of enterprise reform on workers' health care benefits and their financial burden due to medical expenses. This study is based on a 1992 survey conducted in 22 cities, and included 406 enterprises and 5920 workers. It was found that there were wide variations of coverage for health care benefits among urban Chinese workers. It was also found that workers with partial coverage were as likely to incur out-of-pocket medical expenditures as workers without coverage. These out-of-pocket medical expenditures could reach as high as 25% of a worker's annual income. Policy recommendations are discussed at the end of the paper.     

Patient participation in decision‐making on the introduction of home respiratory care: who does not participate?

Objectives In this study we examined home respiratory patients' participation in decision‐making on whether to begin home respiratory care therapy, and this participation in decision‐making during the latest visit to the clinic. Subjects and methods The target population consisted of patients who were using home respiratory care devices and who were visiting the outpatient clinics. Postal questionnaires were sent to 4159 patients (40% of respiratory care device users in Finland). A total of 3336 answered (response rate 80%) and 3153 were eligible for analysis. Odds ratios, chi‐square tests, Mann–Whitney U‐test and stepwise logistic regression analysis were used in the data analyses. Results Patients who did not participate in decision‐making were more frequently older people, women and had lower income than the other patients. While these results parallel those of previous studies, in contrast we found more women with high education to be non‐participants. Non‐participants were not participating in decision‐making during their latest visit to the clinic in spite of the fact that they considered participation almost as important as did the other patients. Non‐participants were less satisfied with the quality of care given and felt that their life had improved less than did the other patients. Conclusion The ethical principle of equal opportunities to participate in care decisions was not applied among home respiratory care patients in this study. The results challenge health‐care professionals to notice inequalities and improve their practices. The results can be generalized to all home respiratory care patients in Finland.     

Long-term care elderly residents in general hospitals

Long-term care facilities for the elderly have regularly to work together with general hospitals to provide care to acutely ill residents or when they require all together more complex diagnostic procedures and multi-specialty care. The decision to hospitalize a nursing home elderly resident is multifactorial and it is based on factors such as illness severity and care facility infrastructure. Hospitalizations have benefits and risks such developing iatrogenic diseases, delirium, and functional decline, which may deteriorate patients' general condition and their quality of life during and/or after hospitalization. This study aimed at addressing specific aspects of assessment, treatment and management of nursing home elderly who require to be hospitalized, especially focusing on their effective care. Common conditions such delirium, iatrogenic diseases, poor nutrition, functional decline, hospice care and special characteristics of nursing home elderly during their admission to general hospitals are discussed.     

Aspects pratiques de la nutrition parentérale à domicile

For 20 years, the number of patients with home enteral or parenteral nutrition is increasing in France. The improvements in regulatory framework and logistic infrastructure allowed to care more patients at home without altering care quality. Education of patients and their relatives, a reliable relation with home care providers, based on a precise specifications, are essential to maintain quality of home artificial nutrition. The regional expert centres for home nutrition will have to have a major role of coordination, assessment, education of the various partners, under the aegis of the SFNEP.     

A conceptual framework for interprofessional shared decision making in home care: Protocol for a feasibility study

Background  

Shared decision making (SDM) is fundamental to informed consent and client-centered care. So far, SDM frameworks have been limited to the client-physician dyad, even though care is increasingly delivered by interprofessional (IP) teams. IP collaboration is especially essential in home care, one of health care's most rapidly growing areas. This study will assess whether it is possible to practice SDM in IP home care.     

Cost‐minimisation analysis of home care reablement for older people in England: A modelling study

Many governments have introduced or encouraged home‐care reablement schemes for older people at home with the aim of improving outcomes and reducing costs. We examined if such schemes have the potential to reduce costs from the perspective of the National Health Service (NHS) and Personal Social Services (PSS) in England. Our study was carried out to inform recommendations of a national guideline. Cost‐minimisation analysis was carried out using decision‐analytic Markov modelling. Home‐care reablement was compared with standard home care. Costs included those of the intervention, home care and hospital admission. Uncertainty was explored using univariate and probabilistic sensitivity analysis. Mean costs per person were £56,499 (95% confidence interval 55,690 to 57,307) in the reablement group, and £58,560 (95% confidence interval 57,800 to 59,319) in the standard care group. The mean difference was ‐£2,061 (95% confidence interval 1,933 to 2,129). The probability that home‐care reablement costs less than standard home care was 94.5% (95% confidence interval 93.1 to 95.9). In sensitivity analyses, this probability remained above 85% in all scenarios. Home‐care reablement can be a successful cost‐minimisation strategy for supporting some older people. More research is needed about the impact of home‐care reablement on health outcomes for different groups of older people; and the effects of different durations of reablement on outcomes and costs for different subpopulations.     

Group work in a Dutch home care organization: does it improve the quality of working life?

Home care in The Netherlands is facing a trend towards increasing workloads, giving it the image of an unattractive sector to work in. To deal with increasing workloads and their effects, many solutions have been developed, including the concept of team or group work. This paper will address the possibilities, conditions and effects involved in the implementation of group work in home care as a means of improving the quality of working life (QWL) in this sector. To this end I have studied QWL in three jobs in two organizations for home care, one of which implemented group work. This comparison concludes that jobs in the team-based organization are more complete and challenging, bringing more job decision latitude, but also higher work pressure.     

Participation and knowledge related to a nursing home admission decision among a working age population

The number of nursing home admissions for working age people (age 18-64) in the USA has increased. Minimal attention has been given to examining their participation in the admission decision. We use a conceptual framework proposed by Ong and colleagues to examine patient and provider predictors of perceived involvement in the admission decision and their relationship to both knowledge and preferences for continued care. In-person interviews were conducted with an admissions cohort of 205 working age individuals in 17 Maryland, USA nursing homes. Similar to previous profiles, participants were predominately male, of minority ethnic status, and of lower socioeconomic status. Common clinical conditions included cardiac disease (49.8%) and diabetes (27.3%). Slightly over half reported a lot (42.1%) or a moderate (15.2%) level of involvement in the admission decision, while 27.9% reported no involvement. Patient race, insurance source and knowledge of the health care decision maker were related to perceived involvement. Minority ethnic group patients were less likely to be aware of alternate settings for care, while patients who knew the medical decision maker were more aware of alternate settings, as well as their expected length of stay. Participants who perceived greater involvement in the decision more often preferred continued care in the nursing home, relative to their own home or other settings. Ethical, practical and legal concerns support involving individuals in this health care decision. Ways to foster improved communication and interpersonal relationships between patients and their health care provider(s) are thus required.     

Heart failure and community-acquired pneumonia: cases for home hospital?

BACKGROUND: Home hospital is advocated in many western countries in spite of limited evidence of its economic advantage over usual hospital care. Heart failure and community-acquired pneumonia are two medical conditions which are frequently targeted by home hospital programs. While recent trials were devoted to comparisons of safety and costs, the acceptance of home hospital for patients with these conditions remains poorly described. OBJECTIVE: To document the medical eligibility and final transfer decision to home hospital for patients hospitalized with a primary diagnosis of heart failure or community-acquired pneumonia. DESIGN: Longitudinal study of patients admitted to the medical ward of acute care hospitals, up to the final decision concerning their transfer. SETTING: Medical departments of one university hospital and two regional teaching Swiss hospitals. PATIENTS: All patients admitted over a 9 month period to the three settings with a primary diagnosis of heart failure (n= 301) or pneumonia (n=441). MEASUREMENTS: Presence of permanent exclusion criteria on admission; final decision of (in)eligibility based on medical criteria; final decision regarding the transfer, taking into account the opinions of the family physician, the patient and informal caregivers. RESULTS: While 27.9% of heart failure and 37.6% of pneumonia patients were considered to be eligible from a medical point of view, the program acceptance by family physicians, patients and informal caregivers was low and a transfer to home hospital was ultimately chosen for just 3.8% of heart failure and 9.6% of pneumonia patients. There were no major differences between the three settings. CONCLUSIONS: In the case of these two conditions, the potential economic advantage of home hospital over usual inpatient care is compromised by the low proportion of patients ultimately transferred.     

Employee must be reimbursed for post-exposure therapy

The Connecticut Supreme Court decided that medical monitoring and treatment costs that an employee might require as a result of occupational exposure to HIV and tuberculosis must be covered by worker's compensation. This decision is seen as beneficial to high-risk employees, including emergency medical workers, law enforcement personnel, and health care workers. The ruling came in the case of a Stanford, CT police officer who was occupationally exposed to HIV and tuberculosis when he touched medical pads used to soak up body fluids from a criminal suspect who later divulged that he was HIV-positive. Doe was also exposed to tuberculosis when he came into close physical contact with another criminal suspect. The State supreme court ruled that Connecticut's State compensation review board improperly denied the police officer the right to recover reasonable expenses directly related to his job-related exposure.     

Nursing home admission risk and the cost-effectiveness of community-based long-term care: a framework for analysis.

The relationship of prior risk of nursing home entry among applicants for community-based long-term care (CB/LTC) services to cost-effective admission decisions is investigated using decision analytic techniques. It is shown that using such evaluation criteria as have predominated in the major CB/LTC demonstrations, the necessary minimum level of prior risk is well above that typical of those actually enrolled. It is further shown that the remedy usually proposed, increasing the rigor and accuracy of enrollment screening, is unlikely to be of much practical effect. A case can be made, however, for defining the benefits of CB/LTC more broadly, in which case it may become cost-effective to enroll lower-risk applicants.     

Case management decision making: goal transformation through discretion and client interpretation

This study examines the decision-making strategies employed by case managers in a state-funded home care program for the elderly. Specifically, this study applies Lipsky's (1980) theory of street-level bureaucracy to gerontological research on case management decision making in an effort to demonstrate the presence of case management discretion, and the impact of that discretion on home care implementation. Drawing upon individual interviews and focus group interviews, results suggest the applicability of the proposed framework, and indicate the need for policy planners to identify factors for case manager discretion that result in undesirable home care goal transformation.