Care at home by integrating formal and informal care

Warum wurde diese Initiative implementiert?

In Italy, the bulk of long-term care is provided by the family or other informal help, as the network of private and public services is weak. In this context, a crucial role is increasingly being played by migrant care workers for intensive care at home cannot be covered – neither quantitatively nor at sustainable costs – by regular home care services. Furthermore, the gap between the relatively new phenomenon of (often informal) migrant care workers and formal health and social care services has created quality and coordination problems suffered by people in need of care and their families, even if migrant care workers are ‘legally’ employed.

This pilot project, co-financed by a Bank Foundation and a Consortium of Municipalities, aims to overcome these difficulties by integrating public and private funds and human resources by addressing the following shortcomings:

• Continuity of care for older people is often jeopardised by a lack of knowledge about access possibilities to services and about what public and private social and health services in the area are offering.
• Informal carers lack social counselling in order to analyse needs and facilities to be activated, and respite care facilities or other specific support.
• Migrant care workers are often untrained and – e.g. in case of a still persisting ‘illegal’ status – are lacking incentives to participate in training.
• Older people in need of care and/or their families employing home qualified migrant care workers through regular contracts.
• Migrant care workers are hardly monitored and controlled (lack of quality assurance).
• Home care services and residential facilities are unable to satisfy demand – there are long waiting-lists even for people who have been assessed to be eligible for a place in a nursing home.
• Innovation in integrated care is limited.

Beschreibung

From 2006 to 2010, a pilot-project entitled Casa Amica Notte e Giorno has been promoted by the Consortium Cidis-Orbassano, consisting of six municipalities in charge of social service provision in the Province of Torino (Piemonte Region, Northern Italy). The pilot-project has been co-financed by the San Paolo Bank Foundation and entailed the implementation of eight instruments to improve care for older people in their own homes and implement an integrated system of home services for older people needing LTC.

• Care voucher: Older people in need of LTC can purchase personal home care services by employing migrant care workers (directly) or by accessing home care services provided by registered organisations. Migrant care workers provide 24hr at home services; the registered organisation provide just a few at home services like respite facilities in residential care or services at home, replacement service (e.g. weekend substitution), transport to and from medical visits, hairstylist, pedicure, food delivery at home, etc. The voucher amounts to between €700 and €7,000 per year and covers part of the service costs. It is needs and means-tested. Income is calculated on the basis of an ‘Indicator of the Economic Situation’ (ISEE) that takes into account the individual income and the income of family members (e.g. wife, sons and daughters, brothers and sisters) who are legally obliged to care for the older family member.
• Access point: The unique access point aims to facilitate matching of care demand and supply, in particular through migrant care workers; the access point helps older people find qualified workers and provides support in completing forms and in defining a regular contract between the migrant care worker and his/her family.
• Task force tutoring: The Consortium guarantees monitoring, tutoring and control of the relationship between the older person and the migrant care worker by professional home care workers. Staff support migrant care workers in the start-up phase, carry out periodic supervision visits at home and represent a central point of reference for older people and migrant care workers.
• Register of migrant care workers and accredited organisations: Each migrant care worker and each organisation must register by demonstrating that defined requirements in terms of qualification and other aspects are met.
• List of services that may be purchased by means of care vouchers: e.g. care provided by live-in migrant care workers (24 hours), respite facilities in residential care or services at home, substitution during a migrant care worker’s holidays or emergency, transport to and from medical visits, hairstylist, pedicure.
• An information campaign to promote the pilot project and to provide citizens with information about available instruments and resources.
• Evaluation research about user satisfaction of older people and informal carers: The Consortium has carried out a study to measure satisfaction levels of care voucher users and informal carers.

The budget of the pilot-project (2006-2010) was €404,506 and was mainly used to fund care vouchers; about 90% of the budget (€370,000) was funded by the San Paolo Bank Foundation during the pilot phase. Pilot-project budget refers to the project’s total duration and it includes all costs needed for the global re-organisation of the home care system, except costs needed to finance Consortium staff. The budget was set in order to provide care vouchers for 12 months for 72 users, to plan and provide a home care tutoring training course, to cover organisational costs for the access point, and to set an evaluation system of users’ satisfaction and interventions’ impact evaluation.

Since 2010 the Consortium Cidis-Orbassano has been financing all services through own and regional budgets. It has also funded two additional staff members working within the access point; other staff members were already collaborating with Consortium as employees.

Welche Effekte wurden erzielt?

Care work by migrant care workers has a massive impact on the community because it allows older people in need of care to stay at home and facilitates female labour market participation. No professional service would be able to cover, at sustainable costs, the needs of intensive (up to 24 hours per day) home care.

A study commissioned by the Consortium has measured results and impact of the intervention. From about 90,000 older people living in this Province, 133 had originally applied for care vouchers. On the basis of the fund’s resources, needs and means-testing, 72 requests (54%) were accepted. However, older people who were not eligible for care vouchers could also use the counselling service and the register to employ a qualified migrant care worker with their own resources.

In 58% of cases, care vouchers improved the quality of life for older people and their informal carers. This rate increased to 71% for older people who chose care provided by live-in migrant care workers due to better assistance, less burden for the family, and more time for informal care and personal needs.

43% of older people who chose migrant care workers and 29% of respite service users said that the positive aspects of the intervention were the economic benefit (families’ relief, regular payment, quick reimburse­ment) and the improved care arrangement (home care, company and caring for older people, alleviation of family burden).

Older people considered the chance to receive care vouchers as “unique and rare” and stated that it improved the human and economic condition of their families and themselves.

Most importantly, users were satisfied because they received “clear, correct and simple information”. They also sustained that the procedures for access and use of the care vouchers were “clear and simple”, and they appreciated “help and guidance on how to better use care vouchers”.

A minority of 16% of older people stated that the care voucher led to limited changes only.

The project has demonstrated that this kind of intervention can be successfully reproduced in other areas, if there are adequate human and financial resources available. The project has become a mainstream-service for the Consortium catchment area, but it is also becoming a mainstream service for all Torino Province, if compared with other experimental interventions active in that area.

Worin bestehen die Stärken und Schwächen der Initiative?

Health and economic conditions of older people as well as the availability of family support are the main elements that influence the choice to keep older people at home. The care voucher, even if it is still scarce, represents a strong support for older people’s assistance, while also guaranteeing support for migrant care workers.

Strengths

• The objectives of the pilot project have been fulfilled: it has allowed the Consortium to offer more differentiated facilities and to support families in economic and care duties.
• Quality of life and health conditions of older people have improved and caregivers had the opportunity to take some relief. 

Weaknesses

• Most caregivers said that the care voucher did not affect the choice of staying home as, for instance, the “scarce” amount of the voucher could not influence this kind of choice (Voucher amount is considered “scarce” because its amount only partially covers costs needed to assist frail  older people at home).
• The main worry of families was the restricted project period scheduled for testing the vouchers (only 12 months).
• Older people and informal carers are not used to choosing migrant care workers or other kinds of services through a ‘special list’.
• The Consortium needs to make registers more user-friendly and to inform not only older people and families, but also all other people who might play a functional role in the relationship between the user and his/her migrant care worker. For instance, the existence of a register should be advertised through members of the parish, migrant’s associations and trade unions that already play an active role in the supply and demand of migrant carers. 

Opportunities

• The project is an undoubtedly positive experience, because private and public resources have financed it, but now it needs to be integrated with other interventions and resources provided by the Consortium. By now, the Consortium is considering how to use the knowledge gained by the experiences of the pilot project.

Threats

• In many cases the project has created expectations that the Consortium will probably not be able to fulfil due to current budget restrictions. 
• Migrant care workers continue to be chosen through other channels such as word-of-mouth recommendations among neighbours, friends, acquaintances and parish members.

Impressum

Autor: Patrizia Di Santo
Reviewer 1: Karin Stiehr
Reviewer 2: Rastislav Bednarik
Verified by: Cristina Pukly, Director of Consorzio Cidis Orbassano

Externe Links und Literatur

• Resolution Cidis Orbassano n. 64  of 22/12/2004: ”Istituzione dello Sportello “Casa Amica notte e giorno”.
• Resolution Cidis Orbassano n. 69 of 30/12/2004 e n. 42 del 28/12/2006: “Approvazione bandi: accreditamento organizzazioni e accreditamento assistenti familiari”.
• Resolution Cidis Orbassano n. 16/2005: “Costituzione del Gruppo di Valutazione”
• Report “Casa Amica Notte e Giorno. Soddisfazione degli utenti”

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