Integrated home care and discharge practice for home care clients (PALKOmodel)

Warum wurde diese Initiative implementiert?

The successful discharge of older people from hospital to home care followed by adequate management at home requires sufficient support being offered and an integration of services. There were some common problems in home care and discharge in Finland, such as shortcomings in the flow of information between different professionals and between hospital and home care (particularly at a specialised care level), a lack of clarity on responsibilities and the distribution of work (particularly when discharging a patient from hospital to home care), a reactive as opposed to proactive way of working (ad hoc discharges) and a lack of integration of services (especially for a patient with multiple service needs). Therefore a generic 'Integrated home care and discharge practice for home care clients' (PALKOmodel) was developed during the PALKOproject (1997-2007) through action research with representatives from three hospitals, a home nursing and home-help agency in one social and health care district (a municipality). The main target group was older people (≥ 65 years) who were discharged from hospital to home care with home care services. The PALKOmodel was implemented (=intervention) into 22 municipalities i.e. local authorities (hospitals and home care agencies) in Finland. The intervention was applied to home care and hospital staff (not to clients) and it was assumed that through changing practice, it would also have an effect on clients.

Beschreibung

The PALKOproject was conducted by the National Research and Development Centre for Welfare and Health (Stakes). The study received funding mainly from Stakes, but also by the municipalities, the Academy of Finland and the Finnish Ministry of Education. Twenty-two Finnish municipalities participated in the PALKOproject. The PALKOmodel was focused on:

• the integration of services and the continuity of care across interfaces of organisations,
• the flow of information from one care provider to another, and 
• clients’ self-determination and empowerment (a purpose was to strengthen clients' involvement in decision making). 

One aim of the PALKOmodel was to standardise practices and make written agreements between hospital and home care and within home care, which defined practice, responsibilities and support tools. At the same time the client's whole pathway from home to hospital and from hospital to home was described in writing and made available to all those involved in the pathway. Multidisciplinary teamwork was further emphasised in hospital and in home care. The home care team (home nurses, home aids, doctors) named a working pair (care/case managers), inside the team, to all clients who received home care services regularly. The pair planned and integrated services together with the client, if necessary with the informal caregivers and with other service providers. Further, the pair participated in planning the client's discharge from hospital to home care with hospital staff (nurses, doctors, social workers, physiotherapist). Twenty-two municipalities were involved in the project. The municipalities were randomised into 11 trial and 11 control municipalities.

The PALKOmodel was implemented (=intervention) in the trial municipalities by means of action research during 2002-2003, and in the non-trial municipalities during 2003-2004, after the data from trial municipalities were received. The research guided and supported the municipalities in tailoring municipality-specific practice and in devising an implementation plan, as well as arranging for national seminars and meetings at municipality level. The intervention was applied to home care and hospital staff and the effect of the intervention was assessed through patient outcomes. The PALKOmodel does not demand extra resources or new actors (such as a liaison nurse) since the working pair are appointed from within the existing home care team members. The PALKOmodel did not receive any extra money or resources (for example extra workers) during the implementation process or after the implementation was done. It was therefore funded through regular work and existing resources.

Welche Effekte wurden erzielt?

The effects and cost-effectiveness of the PALKOmodel were tested using a cluster randomised trial (CRT) with Finnish municipalities (n=22) as the units of randomisation. Data consisted of client interviews (at discharge, and at 3-week and 6-month follow-up), medical records and care registers. Further, the changes in home care personnel's job, work satisfaction and the quality of services were studied using questionnaires. The effects of the PALKOmodel did not improve clients' functional ability and health-related quality of life, except physical mobility at 3-week follow-up, but the use and cost of home care services as well as visits to a laboratory or physician decreased. The intervention was focused on staff practice and this effect on clients was thought to be due to this changing practice. The intervention had only been implemented for a short period (1.5 years).

The workers thought that the content of the PALKOmodel was good and the model worked in practice. The PALKOmodel improved the process: clarified and improved the transfer of information, defined roles and responsibilities, standardised practices, helped to integrate services and increased the proactive way of working. Consequently clients were able to use the service less which decreased costs because of a reduction in overlapping/unnecessary work. In addition the PALKOmodel seemed to be a cost-effective alternative to usual care.

The practice has been implemented in 22 municipalities only, though many organisations have expressed their interest in developing their services according to ideas of the PALKOmodel. In fact, there are municipalities that exploit the ideas of the PALKOmodel when developing their home care and discharge practice.

Worin bestehen die Stärken und Schwächen der Initiative?

Strengths

• The PALKOmodel has been tested using an experimental study design. The PALKOmodel seemed to be a cost-effective alternative to usual care, and it can help municipalities in developing their home care and discharge practice towards becoming more integrated and effective.
• The PALKOmodel improved the process. When the right information is in the right place at the right time the work is more effective (overlapping work and unnecessary work decrease) and the quality of care is better.
• The PALKOmodel does not demand extra resources or new actors but is funded through existing resources and subsumed within normal working hours. In the long term the savings are achieved by an effective way of working.
• The PALKOmodel is generic and goal-orientated, making it usable for all client groups in different settings and organisations.

Weaknesses

• Despite the high interest expressed about the PALKOmodel in municipalities, little progress has been made towards changing current practice. New ideas take time to process and thus it takes many years to achieve permanent changes in every worker's individual practice. There should be more time and more funding to develop practice. 
• The staff involved in developing and changing practice have different professional cultures and styles (health and social sector, hospital and home care, nurses, doctors, home aids). Professional attitudes also need to be changed. 

Opportunities

• In general, by offering adequate care and services at the right time it is possible to prevent or at least slow down the deterioration of clients' functional ability and health-related quality of life. Thus, the clients are able to live at home as long as possible. The PALKOmodel promotes the integration of services and the continuity of care across interfaces of organisations as well as being a proactive way of working.
• In Finland, most clients are not yet, in practice, sharing the decision making process concerning their care. The PALKOmodel emphasises clients' self-determination and shared decision making. 

Threats

• There is too little money and too little time to develop and change work routines in this area.
• Different professional backgrounds are hindering the development of practices across organisations and between professionals.
• The policy makers and managers are not involved in developing home care and discharge practice in municipalities.

Impressum

Externe Links und Literatur

• Pöyry P, Perälä M-L. (2003) Tieto ja yhteistyö yli 65-vuotiaiden hoidon ja palveluiden saumakohdissa (Information and co-operation at the interfaces of care and services for over 65-year-olds). Helsinki: Stakes (aiheita 18). 
• Grönroos E, Perälä M-L. (2005) 'Home care personnel's perspectives on successful discharge of elderly clients from hospital to home setting' in: Scandinavian Journal of Caring Sciences, Vol. 19: 288-295. 

More information: 

• Hammar T, Rissanen P, Perälä M-L. (2009) 'The cost-effectiveness of integrated home care and discharge practice for home care clients' in: Health Policy, Vol. 92: 10-20. 
• Hammar T. (2008) Palvelujen yhteensovittaminen kotihoidossa ja kotiutumisessa / kotihoidon asiakkaiden avun tarve ja palvelujen käyttö sekä PALKO-mallin vaikuttavuus ja kustannus-vaikuttavuus (Integrated Services in the Practice of Discharge and Home Care (PALKO) - Home-care clients' use of services and need for help, and the effectiveness and cost-effectiveness of the PALKO model). Helsinki: Stakes, Research Reports 179 (Doctoral Thesis in Finnish; abstracts in English and Swedish.  
• Hammar T, Perälä M-L, Rissanen P. (2007) 'The effects of integrated home care and discharge practice on functional ability and health-related quality of life: a cluster-randomised trial among home care patients' in: International Journal of Integrated Care, Vol. 17. 
• Perälä M-L, Rissanen P, Grönroos E, Hammar T, Saalasti-Koskinen U, Pöyry P, Noro A, Teperi J. (2004) Integrated Services in Hospital Discharging and Home Care – Results of Baseline Evaluation. Proceedings of the Integrated Care conference, 19–21 February 2004, Utrecht: Igitur Publishing and Archiving Services. 
• Perälä M-L, Hammar T. (2003) PALKO-malli - Palveluja yhteen sovittava kotiutuminen ja kotihoito organisaatiorajat ylittävänä yhteistyönä (Integrated Services in the Practice of Discharge and Home Care across organisations) Helsinki: Stakes (aiheita 29).
• Toljamo M, Perälä M-L. (2008) Kotihoidon henkilöstön työn, työtyytyväisyyden ja palvelujen laadun muutokset PALKO -hankkeen aikana. Kysely kotihoidon henkilöstölle vuosina 2001 ja 2003 (The Changes in Home Care Personnel's Job, Job Satisfaction and the Quality of Services during the PALKOproject. A Survey of Home Care Personnel in 2001 and 2003). Helsinki: Stakes (raportteja 7). [in Finnish] [abstract in English]

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