Bridging the gap between nursing home and community care (the Skævinge Project)

Why was this example implemented?

The assumptions behind the initiative were:

• Self-care should be encouraged and health personnel educated to understand the value and effect of developing and supporting citizens in the self-care principle, where the older people are helped to learn to do as much as they can for themselves but always with the support needed.
• The nursing home, in its current form, should shift to become a health centre with private rented residences for frail older people. A 24 hour integrated care service should be put into operation and made accessible to the entire municipality, this way even very frail older people can stay at home as long as possible.
• Multidisciplinary personnel would, through training programmes, develop their professional competencies in teams, and work together in a different way than before, both in people’s own home and at the apartments for frail older people.

The project addressed the gap between nursing home and home care services and developed the integrated health care system together with the first Danish “24 hour” home care service. The staff groups could work both inside and outside of the nursing home.

Furthermore, by developing new attitudes among the staff towards the older people (identities), the nursing homes were de-institutionalised into private housing with a high degree of user involvement and interdisciplinary mutual respect amongst the staff.

The former nursing home residents had their pension paid back (where before they received pocket money) and were thus able to pay for their own living costs using their pension and 60% of their social income.

Description

All groups of health associated personnel participated in carrying out the project: nurses, home helps, occupational therapists, physiotherapists, administrative personnel, politicians and doctors and, together with users, they set aims for the ongoing action research process. The attitude towards older people was changed using the self-care theory, where the elderly persons are helped to learn to do as much as they can themselves but always with the support needed from the staff groups.

The project gave rise to a new law concerning the transformation of nursing homes into housing for older people. The users received their full pension instead of pocket money and used this to pay for their living costs.

There was ongoing implementation of new ideas and use of the press (newspaper, video and TV). Later the politicians and staff went out to talk about the project and visitors from all parts of Denmark, as well as from Japan, USA and other European countries, came to hear about the project.

Costs: Funds from the Ministry of Social Affairs were donated for the project leaders’ salary as well as funding for rebuilding of older people’s housing. The overall costs decreased, although the group of older people increased by 30% in the period from 1986 to 1996.

A video called “The Force of Habits” was produced to show the development and processes used and one million Dkr were funded by the National Board of Health.

What are/were the effects?

The project addressed the gap between nursing home and home care services and developed the integrated health care system together with the first Danish 24 hour home care service and the staff groups could work both inside and outside of the nursing home.

A '10-years onward' evaluation was requested by the politicians to measure the sustainability of the Skævinge Project. The Danish Health Institute undertook the investigation (Knudsen et al, 1999) described from three perspectives:

The Citizen’s perspective discloses the living conditions, health status and mobility, knowledge and health benefits. A questionnaire survey in 1996 was compared with an identical one undertaken in 1986. The older people’s mobility, measured by means of ability to undertake activities of daily living, remained generally unchanged, but a larger proportion of older people in 1996 were in a position to make their own food and wash their own clothes without difficulty. More people in 1996 assessed their health status as better in comparison with those of an equivalent age group in 1986.

The Personnel’s view was investigated by individual and focus group interviews. The interviews left little doubt that the project in 1996 was a success from the perspective of the personnel, administrators and politicians. The long and thorough preparatory process made the personnel motivated and involved in the decision-making process and influenced the on-going developmental processes; they expressed ownership and responsibility.

The Society’s view pointed at them being in a position to establish interim guest rooms, which replaced County Hospital functions, to facilitate early discharge from hospital in the best interest of the users, regardless of municipal costs.

In 1986 the running costs were the equivalent of 18 million Danish kroner (Dkr) in 1996 prices; whereas in 1996 this amounted to 14 million Dkr. The new identity and organisation was able to reduce the running costs at a time when the number of older people increased by 30%.

The project has been partly implemented in parts of the USA, Japan and other European countries. New laws in Denmark have been influenced by the project and a 24 hour service was fully implemented by 1999.

What are the strengths and limitations?

Strengths:

• The bottom-up approach and action research process enabled the staff and users to develop their own ideas and positively influence the development of care and organisation of daily living with a high influence of the user. Politicians showed the necessary confidence and patience throughout the process.

Limitations:

• It is difficult to identify exact reasons for the better health outcomes, but there seems to be a trend showing that this way of dealing with development of identity and organisations in a municipality influences the citizens’ feeling of better health and security. 

Credits

External Links and References

Books and book chapters:

• Wagner L. (1988). Skævinge-projektet, En model for fremtidens primære sundhedstjeneste [The Skaevinge Project, A Model for Future Primary Health Care Service] ISBN: 87-7316-502-6 (In Danish).
• Wagner, L. (1994). Innovation in Primary Health Care for Elderly People in Denmark, Two Action Research Projects / Nordic School of Public Health, Sweden ISBN: 91-97-1684-4-0 (Thesis).
• Knudsen MS, Christensen JK, Friis S.&, Wagner L. (1999). Skævinge-projektet 10 år efter: Undersøgelse af en integreret sundhedsordning. [The Skaevinge Project – 10 years after: Investigation of an Integrated Health Care Programme.] Copenhagen DSI, Danish Institute for Health Services Research. ISBN 87-7488-344-5 (resume in English).
• Wagner, L. (1995). 'The Skaevinge Project: A Model for Future Primary Health Care' in: Gamroth LM, Semradek J, Tornquist EM (eds). Enhancing Autonomy in Long-term Care: Concepts and Strategies. New York: Springer: 131-138.
• Wagner, L. (1997) 'Long-term Care in the Danish Health Care System' in: I. Harvey Jolt& MM. Leibivici (eds) Long Term Care: Concept and Reality: State of the Art Reviews – Health Care Management. Hanley& Belfus, INC. ISBN 1-56053-246-7: 149-156.
• Wagner L. (1998) 'Unterstützung zu Hause in Dänemark in den 90er Jahren: Strukturelle Voraussetzungen und Erfarhrungen eines Aktionsforschungsprojektes' in: Pelikan JM, Stacher A, Grundboek A, Krajic K (eds) Virtuelles Krankenhaus zu Hause: Entwicklung und Qualität von Ganzheitlicher Hauskrankenpflege: Theoretische Konzepte, Gesundheitspolitischer Kontext un Praktische Erfahrungen in Europa. Wien: Facultas Universitätsverlag: 78-88.
• Boll Hansen E, Eskelinen L, Sejr T, Wagner L. (1997) Ældres behandlingsforløb. Kbh.: Forum for kvalitet og offentlig service 1997 [The Course of Treatment of the elderly. Copenhagen.: Forum for quality and public service 1997].

Papers:

• Wagner L. (1995). 'Indførelse af nye metoder I pleje og omsorg af ældre I Danmark' in: Tidsskrift for Sygeplejeforskning; 11(2): 25-37 [Implementation of new Methods Concerning Health Care of Elderly People in Denmark. Journal for Research of Nursing].
• Wagner L. (2005) Long Term Care from Global and Local Perspectives, Professorial seminar November 30 2005.
• Wagner L. (2006). 'Two Decades of Integrated Health Care in Denmark' in: Tidsskrift for Sygeplejeforskning 2/2006:13-20.
• Høy B, Wagner L, Hall EOC (2007). 'The elderly patents dignity. The core value of Health,' in: International Journal of Qualitative Studies on Health and Well-being, Vol.2:160-168.
• Høy B, Wagner L, Hall EOC. (2007). 'Self-care as a health resource of elders: an integrative review of the concept' in: Scandinavian Journal of Caring Sciences. Vol 21, No.4:456-466.