As long as possible in one’s own life – sub-project: Home-rehabilitation

Why was this example implemented?

The project was implemented due to anticipated difficulties of funding current service levels – a lack of €6 million by 2020 was forecasted. Furthermore, there was a general desire for a paradigm-shift in providing LTC – from home-help to self-care. Related drivers for change were:

• To counteract the revolving door issue: those capable should be ‘turned in the doorway’ by immediate action and by bridging gaps in transition from hospital to home, including training.
• To counteract the passive receipt of care: from ‘doing for’ to self-determination and self-care.
• To facilitate inter-disciplinary cooperation by addressing this issue with commitment to training and supervision.

The target group of the project were all citizens over 65 years of age, who were discharged from hospital and returning home.

Description

Denmark has five Regions and 98 municipalities, one of which is Fredericia. In 2008 the Fredericia local authority embarked on an ambitious, large-scale project to overhaul LTC services, called ‘As long as possible in one’s own life’. Five linked sub-projects were started within two years: ‘Home-rehabilitation’ is the focus of this example. However, it is important to mention the other sub-projects to show that the intended paradigm-shift towards better understanding of self-care in provision of LTC was addressed on many fronts simultaneously:

• ‘Prevention’ addressed the gap in awareness of incipient problems that can lead to the need for home care.
• ‘Home from hospital’ addressed the gap in communication between hospital and local authority, between primary and secondary care by tightening up first visits and follow-up by doctors and nurses.
• ‘New technology’ facilitated, for example, electronic pill-boxes or Wii games to increase independence.
• Finally, ‘health promotion’ focused on disseminating more and better knowledge to support and encourage independence and self-care.

The project was promoted by the Health and Social Service Department, Board of Directors, of the Fredericia local authority. It was funded by a National Board of Health grant for ‘Development of Older People’s Care’ and other, smaller grants. The change agent and driver was the Head of Rehabilitation at the local authority and the project was carried out by a multidisciplinary team involving nurses, physiotherapists, occupational therapists, home-help workers and assistants.

The objective of the sub-project ‘Home-rehabilitation’ was to develop, test and implement a model of home training that would reduce, delay and/or prevent the need for compensatory help. Older people returning home from hospital are registered within 2 days (by law) and immediately attached to a physiotherapist to regain capacities and even improve them. Older people applying for home help for the first time are similarly offered a package of home training instead of care.

The design was dependent on all stakeholders signing up and supporting the paradigm-shift. The design allows for adaptation and evolution throughout – close to an action-research model. Implementation demanded a high level of leadership skills, as different sets of workers had to report to different leaders, who had to communicate well and solve issues jointly.

Apart from the costs for development and evaluation, human resources of the Home-Rehab Project stipulated three therapists, one nurse, one project planner and one project leader. 

What are/were the effects?

• External financial evaluation reports have shown annual salary savings of 13% due to a reduced need for compensatory help. Costs continue to fall after the roll-out to new clients and across the whole local authority.
• Leadership and workers agree that the goal of a total ‘paradigm-shift’ in provision has been achieved. The next goal is how to sustain and further develop this approach.
• The gap between hospital and transfer to home is reduced by effective co-ordination and communication between hospital and local authority assessors/nurses.
• Case studies with clients show very broad satisfaction with increased self-care and reduced hours of care. Internal monitoring shows that self-care is largely maintained by those who have been trained.
• An evaluation with workers is ongoing and includes informal reports of satisfaction with working in multidisciplinary teams. It seems that the new supervisory role – training and leading home care staff – is causing feelings of pressure. The question will be how to sustain the required high levels of motivation for team members working across disciplines.
• Leadership report high levels of overall satisfaction with cost savings and increased self-care among clients.
• As often with pilot projects, there are many enquiries from other local authorities on how to transfer the model to their own settings. This entails an additional time burden on local authority management but shows the success.

What are the strengths and limitations?

Strengths

• Clients who would otherwise be likely to become passive receivers of ongoing care can be ‘turned in the door’ by being offered a package of training and rehabilitation with the aim of restoring and improving self-care, thus reducing the need for home care and inpatient rehabilitation.
• The example shows that effective multidisciplinary work can be achieved, both across settings (hospital/local authority/home) and within teams – nurses, therapists and home workers.
• Bottom line savings can be achieved with this approach.

Weaknesses

• Success depends on well-managed and highly motivated teams, who buy into the paradigm-shift. Communication with clients to ‘sell’ the idea to them is important and there may be a need for continuous training if self-care is to be maintained for longer periods.

Opportunities

• Current monitoring shows that savings continue to be made after the initial pilot and roll-out.

Threats

• The pressure to maintain required high levels of motivation after the initial success will challenge leadership to find strategies to continually enable and improve team working.

Credits

Author: Lorna Campbell / Lis Wagner
Reviewer 1: Thomas Emilsson
Reviewer 2: Patrizia Di Santo
Verified by: Louise Thule Christensen, Project Leader (Email: sttc@fredericiakom.dk)

External Links and References