Looking for integrated elderly care in practice

Anna-Mari Juutinen (Department of Health and Social Management, University of Eastern Finland UEF, Kuopio, Finland)

Journal of Integrated Care

ISSN: 1476-9018

Article publication date: 12 July 2023

Issue publication date: 18 December 2023

642

Abstract

Purpose

The goal of integrated, multidisciplinary and person-centered care is on the welfare policy agenda in many countries, but how about integrated service delivery in action? This paper describes a three-year service journey of an elderly person from home to a nursing home through home care, specialized hospital and inpatient care. The aim of this viewpoint paper is to consider how customer orientation and integration are realized when an older lady living an active life becomes seriously ill and loses the ability to conduct daily functions.

Design/methodology/approach

The service path will be described from the perspective of a relative.

Findings

The paper raises questions related to governance as well as multidisciplinary and customer orientation in integrated care.

Originality/value

The paper discusses a real-life experience of an elderly care journey from active senior life to a nursing home in Finland. When making visible an elderly care journey, this gives real-life information about the challenges and the needs for development. Better practical understanding helps to remove inter-organizational barriers toward more integrated and patient safe care.

Keywords

Citation

Juutinen, A.-M. (2023), "Looking for integrated elderly care in practice", Journal of Integrated Care, Vol. 31 No. 5, pp. 85-89. https://doi.org/10.1108/JICA-05-2023-0025

Publisher

:

Emerald Publishing Limited

Copyright © 2023, Anna-Mari Juutinen

License

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode


Introduction

Although the national social, health and welfare systems differ from country to country, the objective of integrated care is a common one (WHO, 2015; EU Commission, 2017). It improves the quality of services and the efficiency of the service system and increases staff and customer satisfaction (Kodner, 2009; Auschra, 2018; Connelly and Fiorentini, 2021). One of the key principles in integrated care is the customer's active and participatory role in one's own care (Goodwin et al., 2017). As a relative of a long-term patient and a PhD candidate studying integrated care, I have gained insights ranging from the system to the person level. For 20 years, I worked at the local organization providing public social and health services with about 1,700 employees. I worked as a developer, technology manager and data analyst aiming to renew services and processes more efficient. I started my doctoral dissertation at the Department of Social and Health Management at the University of Eastern Finland in 2017, after a local pilot project with the goals of youth service integration ended. I have also gained significant personal expertise of integrated elderly care. This started the day before my mother turned 80 when she suffered a large-scale cerebral hemorrhage.

The goals for person-centered integrated care in Finland

In Finland, one of the Nordic welfare states, integrated care has been the focus of national public sector reform which started in 2023. The public welfare and health services based on the legislation are to be organized into 18 welfare counties and funding is to be transferred from the municipalities to the national level. Based on the reform act the welfare counties will be responsible for integrating the municipal, national and other services into person-centered services (Act 612/2021, 2021) Pilot programs for this change have been conducted through national integrated care pilot projects related to services for the elderly, families with children and people with disabilities (Hallitusohjelma, 2019).

One journey from independent living to long-term elderly care

I have studied the theories and the policy papers of integrated care from 2017. In addition to this I followed my mother's care journey over the last three years. The distance between the policy strategy and integrated care in action seems large. Until the age of 78, our mother lived an independent and active life alone. She enjoyed singing in a choir, outdoor activities, housework, took care of herself and met friends and relatives. She loved swimming and cycling. Nine years before falling ill, she moved to a communal apartment for the elderly, where she got new friendships with all essential services nearby. We three adult children with grandchildren were important to her and she visited us often.

When she turned 78, we family members noticed changes in her daily life and behavior. She would call and tell us that she was worried, felt lonely or was in a bad mood. When visiting her, she made coffee and there were no visible problems. At the age of 79 things changed. She found it challenging to cope with everyday matters. She forgot the appointments with the doctor, the chiropodist and the hairdresser. She lost her cell phone, wallet and keys at some point. Yet she did not mention the visits to the health center.

The social and health center started regular home care nurse visits without telling the family. The reason for the nursing care was medication problems. Mother forgot to take medicine, the drugs got messed up or she took the drugs several times a day. Although the nurse supervised the medication, mom's condition did not improve. She was very tired, slept a lot, could not tell evenings from mornings, spoiled food found in the fridge and her visits to the friends and relatives became less frequent. In 2020 we started preparing the party for her 80th birthday. It used to be very important for her to celebrate birthdays with the family and the friends. This time she refused to participate in the celebration of her own special day.

Ultimately there was no party, because the day before her birthday our mother suffered a serious illness attack. Almost a yearlong care journey from home to nursing home started (Figure 1).

During a morning visit the home care nurse noticed something wrong with our mother and called an ambulance. At the specialized university hospital, extensive cerebral hemorrhage caused by vascular dementia was diagnosed. Vascular dementia – how could we family members not know this diagnose? The neurologist from emergency care told us there was nothing to do. We just had to wait and see what would happen. After three days she was unexpectedly transferred from the emergency care to the specialized acute inpatient ward.

A week later they transferred her to the acute internal medicine ward at the local health center. After two weeks she was transferred to the neurological rehabilitation ward in the same hospital. An intensive rehabilitative therapy, physiotherapy, speech therapy and occupational therapy started and mother began to recover with baby steps. After two months of rehabilitation, the therapies were stopped. Staff told us that our mother was given the option of long-term care. Based on a decision she queued for a place in an elderly home for six months. With the status of a long-term patient, no rehabilitation therapies occurred. Presently mother has lived in the nursing home almost one and a half years. Housing, care and cure, doctor's appointments and meals are included in the elderly care fee.

Integration as mutual understanding

Due to a cerebral hemorrhage mother lost her ability to speak, so we family members tried to interpret and communicate her needs to staff. It was not easy, even impossible. Whatever we conveyed never seemed to reach the next shift. We witnessed patient injuries related to ward or room transfer and left unattended. At times she was found on the floor of the room or bathroom, or on another bed. This occurred repeatedly in four units.

What surprised me most was the impact of the decision-making of long-term care at the rehabilitation ward. After ending the occupational, speech and physiotherapy, our mother's functional capacity began to decline. She became frustrated and depressed, even suicidal talk. When the symptoms appeared, only the medication was increased. We family members started to rehabilitate her in our own non-professional way until moving to a nursing home after six months queuing.

Now after one and a half years at the nursing home our mother appears to have settled in, even though she does not understand where she is and who the people around her are. She has some mobility inside the ward with a rollator or in a wheelchair when she is assisted. When visiting her, she often stays on her own while the staff are busy due to limited resources. She is not able to read and has a lack of energy to watch television. With the family she feels safe, asks some questions and speaks short sentences.

I used to sing old songs during my visits. Even though she has difficulties with speech and cognition, she hums and sometimes even sings with me. One day when I was leaving a nurse approached me. She said that mother is satisfied and calm for a long time after the singing sessions. The songs increase positive feelings, even though she doesn't remember my visit. This is an example how the patient's own memories and recourses can be activated and utilized to support care. It also increases one's quality of life and reduces the burden on nursing.

Towards more personalized and integrated care

As a relative and an integrated care researcher it seems unclear how person-orientation can be realized in situations when the patient is unable to speak and there is negligible or no discussion together with significant others. The dialog with caregivers, significant others and the patient is essential toward holistic, integrated, person-centered and patient safe care. Especially transferring the patient from one unit or a room to another must be seen as a need for integration instead of a risk in patient injury. Based on my experience it seems the person-centered care and the quality of services depends on how much family members have time to participate, monitor and evaluate the services. Regardless the feedback and wishes have not always been welcome.

From the perspective of this case, multidisciplinary care is rarely visible. I hope for more rehabilitative care to be included in the daily elderly care and cure. The processes need to be developed with the expertise of multiprofessional teams including the functional aspects of patient care, as well as speech and physiotherapy. The evidence-based knowledge and ideas of clients and relatives must be utilized to develop and implement good practices. Enriching the elderly's everyday lives by adding music, play and body movement in cooperation together with the volunteers and the third sector is also important. This means that integrated care has to collaborate with non-governmental organizations.

Based on the theories and the experience of my mother's journey, I found personalized care, multiprofessional competence and multidisciplinary management as a key ingredient toward more person-centered elderly care. A personalized and holistic care plan is needed but it should not be just a summary of occurred services. It must also identify one's physical, mental and social abilities, interests and limitations also, like a plan of one's quality of life. The goals of plan must be set, evaluate and refine together with the patient, the significant others and the professionals. The significant others as a resource should not be forgotten. And when the patient is transferred from one unit to another, the personalized plan needs to be communicated carefully to staff with the new unit.

Who cares integrated care?

Several researchers have found integrated care a multilevel and complex system (Valentijn et al., 2015). The implementation of integrated care is complex and difficult, too (Emerson and Nabatchi, 2015). As an integrated care researcher, a developer and a daughter of a long-term patient, I agree with this. Implementing integrated care requires large-scale cultural, organizational and political change and much more multiprofessional cooperation (Miller and Stein, 2020). But this is not sufficient on its own, I think. If integrated service delivery does not meet the persons' needs, capabilities and wishes, it cannot lead to the positive outcome we all want.

The system-level integration is a large-scale cultural change with training in knowledge and attitudes for professionals and time for multidisciplinary work (Stein, 2016). Without multidisciplinary decision-making or shared objectives true integrated care is not possible. But we need to remember that integrated care is not a temporary or short-term developing project. Continuous learning from experience, evaluation of the outcomes and disseminating evidence-based practices are essential. The goals for care integration must be measurable as well as subjected to research and evaluation. The political and strategic decision-makers are the key stakeholders when approving the objectives and agenda for care reform toward integration. They must also ensure that person-centered integrated care is achieved against all odds.

Figures

From home to nursing home – integrated or not?

Figure 1

From home to nursing home – integrated or not?

Competing interests: The author declares that she has no competing interests.

References

Act 612/2021 (2021), “Laki sosiaali- ja terveyspalvelujen järjestämisestä”, Voimaantulo: 1.1.2023; osittain voimaan aikaisemmin. FINLEX. Oikeusministeriö, Act on the reform of Health and Social Services. Entry into force: 1.1.2023; partially effective earlier. FINLEX. Ministry of Justice Finland. Available in Finnish only.

Auschra, C. (2018), “Barriers to the integration of care in inter-organisational settings: a literature review”, International Journal of Integrated Care, Vol. 18 No. 1, p. 5, doi: 10.5334/ijic.3068.

Connelly, L.B. and Fiorentini, G. (2021), “Structural factors and integrated care interventions: is there a role for economists in the policy debate?”, The European Journal of Health Economics, Vol. 22, pp. 1141-1150, doi: 10.1007/s10198-020-01253-1.

Emerson, K. and Nabatchi, T. (2015), The Integrative Framework for Collaborative Governance. Collaborative Governance Regimes, Georgetown University Press, Washington, DC, pp. 38-92.

EU Commission (2017), BLOCKS - Tools and Methodologies to Assess Integrated Care in Europe. Report by the Expert Group on Health Systems Performance Assessment, Publications Office of the European Union, Luxembourg.

Goodwin, N., Stein, V. and Amelung, V. (2017), “What is integrated care?”, in Teoksessa, V., Amelung, V., Stein, N., Goodwin, R., Balicer, E., Nolte, E. and Suter, E. (Eds), Handbook Integrated Care, Springer International Publishing AG, pp. 3-24.

Hallitusohjelma (2019), “Osallistava ja osaava Suomi - sosiaalisesti, taloudellisesti ja ekologisesti kestävä yhteiskunta”, Pääministeri Marinin hallituksen ohjelma 10.12.2019. Helsinki: Valtioneuvosto, Inclusive and competent Finland - a socially, economically and ecologically sustainable society. Programme of Prime Minister Marin's Government 10.12.2019. Helsinki: Government. Available in Finnish only.

Kodner, D.L. (2009), “All together now: a conceptual exploration of integrated care”, Healthcare Quarterly, Vol. 13, pp. 6-15, doi: 10.12927/hcq.2009.21091.

Miller, R. and Stein, K.V. (2020), “The odyssey of integration: is management its Achilles' Heel?”, International Journal of Integrated Care, Vol. 20 No. 1, pp. 1-14, No. 7, doi: 10.5334/ijic.5440.

Stein, K.V. (2016), “Developing a competent workforce for integrated health and social care: what does it take?”, International Journal of Integrated Care, Vol. 16 No. 4, p. 9, doi: 10.5334/ijic.2533.

Valentijn, P.P., Boesveld, I.C., van der Klauw, van der Klauw, D.M., Ruwaard, D., Struijs, J.N., Molema, J.J.W., Bruijnzeels, M.A. and Vrijhoef, H.J.M. (2015), “Towards a taxonomy for integrated care: a mixed-methods study”, International Journal of Integrated Care, Vol. 15 No. 1, p. e003, doi: 10.5334/ijic.1513.

WHO (2015), WHO Global Strategy on People-Centred and Integrated Health Services. Intemin Report, WHO Press, Geneva.

Acknowledgements

The author is grateful to colleagues for the encouragement to write this paper and the comments on a previous draft. The author dedicates this writing to the author’s mother, who is living in an elderly care home.

Funding: This is an independent and self-funded paper, prepared and published as a part of author’s Welfare, Health and Management WELMA Doctoral Studies at University Eastern Finland UEF. The views expressed are not those of the Department or the Doctoral Program.

Corresponding author

Anna-Mari Juutinen can be contacted at: anna-mari.juutinen@uef.fi

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