Integrated care in a Hospital with Polyclinic

Why was this example implemented?

Slovakia is in a stage of developing a system of LTC services as they are understood in today´s concepts of modern health and social care. With the growing number of older people with chronic disease and disabilities and rising constraints of families to provide informal care, addressing the development and promotion of formal health and social care for older people whilst at the same time supporting families and carers is urgently needed.

Although there is no special legislation for long-term care, the Slovak Ministries for Health and Social Affairs have tried to formulate the scope and purpose of LTC services under their respective responsibilities. Furthermore, they provide guidance for their practical implementation, but financing LTC services in a reliable manner on national, regional and community levels has remained an unresolved problem. LTC facilities for older people that are run by the state and/or municipalities have to charge co-payments from clients. LTC facilities for older people run by the private sector are too expensive for most of the population. Against this background, combining health and social care facilities is a major challenge in the Slovak context. Currently only 14 hospitals in Slovakia have applied this practice of linking health and social care under one joint organisational umbrella (Repkova, 2011).

The major reason for integrating a care home and social care facilities (HUMAN) to the RM-H general hospital was due to demographic changes in the region that resulted in an increasing number of older patients, the majority of whom were suffering from chronic disease. In addition, the region has been characterised by an absolute lack of organisations providing social care services as well as by high rates of unemployment and emigration of younger people. While the General Hospital serves patients of all ages, HUMAN serves exclusively older people with severe chronic disease or disability, acute hospital stays leading to long-term care needs, or for people in difficult social conditions who are unable to care for themselves.  For these target groups, HUMAN provides 13 places with services provided by qualified staff who can also rely on specialised doctors’ support from the hospital.

Description

The example has been developed by the private not-for-profit organisation Revúcka medicínsko-humanitná n.o. (RM-H) and consists of two settings in one place under one administrative umbrella, but based on two different legal regulations:

1) The general hospital with its polyclinic was established under health legislation to provide in-patient health care with departments for internal medicine, surgery, gynaecology and obstetrics, neonatology and paediatrics, long-term care, and intensive care. It has 135 beds, out of which twenty are reserved for long-term care patients. Out-patient services also comprise gastroenterology, trauma, ophthalmology, neurology, orthopaedic and geriatric care.

2) The care home HUMAN was established under the Social Services Act and provides comprehensive nursing and social care by professional staff. It has six places with a nursing home licence and seven places for social care and rehabilitation.

Given the distinction between health and social care financing, the RM-H facility is funded by different sources: health care provided in the general hospital and its polyclinic is funded via compulsory health insurance (contributions for pensioners are paid by the state). Social care provided in HUMAN is funded by means of client fees and by regional government subsidies that are negotiated on an annual basis. Eligibility criteria for the admission to HUMAN consist of age (62+) and care needs according to the Act 448/2008 Coll. on Social services.

The occupancy rate of HUMAN is 100% as the number of requests exceeds its capacity. Most of the clients are admitted directly from the LTC department of the hospital, but many are also referred from other hospitals in the region or from home. The average age of clients is 82.2 years (ranging from 62 to 95 years).

Upon admission to HUMAN, each client is interviewed to assess his/her needs and to define a “social care and rehabilitation plan”. The work with clients is carried out in two ways: through a facility work plan and through an individual developmental plan.

The facility work plan focuses on the provision of social care, group work with clients including  communication, rehabilitation and mobilisation while taking into account the physical and mental health conditions of the clients. It is updated and adjusted according to actual needs and opportunities, e.g. thanks to donations it is possible to purchase new devices and care aids. The spiritual well-being is ensured by visits by church representatives. The cultural programme comprises books being read by staff, watching TV and listening to the radio with follow-up debates about the programme. The clients can walk and work in the garden, help in the kitchen, and thus also improve their abilities for daily living.

Staff are professionally trained and skilled to work with older people and consist of three social workers (one of them the facility manager) and four nurses. This is in line with legislation on personnel norms in social care facilities. An advantage in this particular case is the “co-existence” with a hospital, from where physicians are called to provide necessary health care or to decide on a transfer of the patient. The HUMAN clients have also access to all rehabilitation facilities in the hospital, where they can profit from additional or controlled examinations.

HUMAN is registered as a social service provider. It charges clients from €16.50 per day for accommodation, meals and social care regardless of the length of stay. On an annual basis, management negotiates a discretional subsidy with the regional government. If health care services are needed, these are provided by the hospital which claims reimbursement from the public health insurance. 

What are/were the effects?

Between 2007, when the facility was opened, and June 2011, 87 patients/clients were admitted. Due to their high age and multimorbidity, 40 residents died in the facility; 19 were re-enabled to live autonomously at home thanks to the comprehensive care provided (HUMAN annual reports).

An evaluation has been performed measured by GDS-15 tests, gathering information from personnel and relatives. Results demonstrated improved health outcomes regarding the following: improved self-care /ADL skills; improved mobility e.g. through training to learn how to walk with crutches; improved mental condition, increased social interaction and “willingness to live”.

The model of integrated health and social services is highly supported by the hospital management to ensure the follow-up of the patient so that his/her condition does not deteriorate after discharge from the hospital. HUMAN not only provides nursing care and comprehensive social care services, but helps the clients to identify and arrange relevant home care services in case their condition allows them to live at home again. If this is not the case, HUMAN provides life-long services. Indeed, there are manifold problems regarding the discharge of clients from HUMAN. In most cases they do not have relatives to step in as informal carers and simultaneously there is a lack of home care services provided by the municipal or regional authorities. As these clients are pensioners and this region belongs to the poorer ones with a high unemployment rate, the option of private providers is not applicable because they cannot afford out-of-pocket payments.

What are the strengths and limitations?

Strengths

• The model of integrated care  introduced by RM-H, i.e. providing health and social care under one organisation at one spot and sharing the material, technical, personnel capacities of both settings (acute hospital and HUMAN) has proved to be a cost-effective and efficient way to deliver timely and quality LTC services with satisfied patients/clients and improved health outcomes. It is a good example for other hospitals. At present there are 14 public hospitals throughout Slovakia that have decided to complement health services by institutional and/or daily social services in a similar way as in Revúca.

Weaknesses

• Insufficient number of beds in HUMAN to meet the regional demand.
• Remuneration of personnel is low.
• Poor links to residential and/or community care as these are underdeveloped or do not exist at all in the vicinity of clients who could live at home with some support.

Opportunities

• Multi-source financing of LTC from public and private sector to ensure the stability and further development of HUMAN.
• Assistance from volunteers in social care and daily living would certainly be an asset for personnel and clients alike.

Threats

• Under financing from public health and social sources may lead to destabilisation of staff and charging higher fees from clients. 

Credits

Author: Darina Sedlakova, WHO Country Office in Slovakia
Reviewer 1: Kai Leichsenring
Reviewer 2: Jenny Billings
Verified by: Viera Peliova, Director of HUMAN

External Links and References

• Repková, K. (2011). Verejní a neverejní poskytovatelia sociálnych služieb na Slovensku – analýza Centrálneho registra poskytovateľov (Public and non-public social services providers in Slovakia – Analysis of the Central Register of providers). Bratislava: IVPR.
• Výročné správy RM-H, n.o.