5. Organisational Structures
Organisational structures provide LTC services at various stages along individual care pathways. Often two or more services (eg home-help, acute medical treatment and rehabilitation) provided by different organisations and often in different settings have to be available at the same time. Therefore organisational structures need to take on interlinking and coordinating approaches, which foster inter-professional and cooperation between organisations and allow them to match specialised services to comprehensive personal needs of older people and informal carers at the same time. The implementation of such interlinking and coordinating approaches represents a crucial precondition for seamless LTC pathways and processes, and can take place within different settings.
Each sub-theme in this theme represents an LTC setting or facility. A list of possible approaches is provided for each sub-theme. It is important to elaborate on how these approaches are organised to promote seamless care.
5.1 Nursing and residential care homes
Examples of this type of institutional care include a consideration of the approaches listed below. The question to be answered is: how do care homes organise approaches such as these in order to promote seamless care? Examples include at least one of the following key issues:
- Multi-disciplinary teams
- Structures that facilitate individual and multi-professional care planning
- Integrated access points (eg concerning referral, financial issues, payment regulation, one-stop-shops)
- Programmes integrating prevention/rehabilitation/reintegration
- Facilities that help preserving and maintaining informal family relationships
- Structures that facilitate free choice and access to additional external services including medical (own GP), social (own hairdresser, friendships) or voluntary services
- Diversity-friendliness: recognition of the specific care needs of hard-to-reach groups
5.2 Care within a hospital setting
This sub-theme includes the role of general or geriatric hospitals, specialised wards (eg palliative care), or out-patient services for people in need of LTC. How do hospital settings organise approaches such as those in the list in order to promote seamless care? Examples include at least one of the following key issues:
- Multi-professional teams for assessment, care and treatment
- Flexible out-patient/out-reach services/ geriatric ambulatory teams
- Integrated prevention, rehabilitation/remobilisation/reintegration programmes
- Access points (referral, one-stop-shops)
- Day clinic services
- Structures that facilitate communication and planning with existing formal care resources and informal carers
- Structures that facilitate integrated discharge and follow-up planning
- Diversity-friendliness: recognition of the specific care needs of hard-to-reach groups
5.3 Transitory care facilities
These include temporary care within an institution or facility such as respite care, day care, intermediate care or rehabilitation units. How do these facilities contribute to promote seamless care? Examples include at least one of the following key issues:
- Structures that facilitate communication and planning with formal care resources and informal carers
- Access points (referral, one-stop-shops)
- Structures that facilitate re-assessment and follow-up planning
- Structures that facilitate individual and multi-professional care planning
- Integrated prevention/rehabilitation/remobilisation/reintegration programmes
- Diversity-friendliness: recognition of the specific care needs of hard-to-reach groups
5.4 Assisted living arrangements
These can be described as sheltered or warden assisted accommodation, and may be seen as a halfway house between living at home, in a nursing home or in residential care. How do assisted living arrangements organise approaches such as those in the list in order to promote seamless care? Examples include at least one of the following key issues:
- Structures that facilitate individual and multi-professional planning of care and living arrangements eg care communities, small units, service housing, sheltered housing (ie without care facilities)
- Access points (referral, one-stop-shops)
- Structures that facilitate preserving and maintaining informal family relationships
- Structures that facilitate free choice and access to additional external services including medical (eg own GP), social (eg own hairdresser, friendships) or voluntary services
- Structures that facilitate coordination with formal care resources (eg prevention and/or rehabilitation)
5.5 Formal care in the home and community
These care services are those that are provided at home and in the community in order to maximise independence and prevent admission to institutions. They include mobile or outreach teams, palliative care, migrant care, and will also include community-based innovations between LTC and health and social care, such as care farms, meeting centres for people with dementia and other care needs. In addition, general practitioners, therapist and independent practitioners are also included. How is formal care in the home and community organised and structured to promote seamless care? How are public, private for profit and non-profit organisations contributing? Examples must include at least one of the following key issues:
- Access points (referral, counselling, one-stop-shops)
- Flexible and adaptable services to suit individual needs and individual lifestyle
- Multi-professional teams (eg preventive/rehabilitative measures)
- Structures that facilitate coordination and cooperation with other formal and/or informal care
- Structures that facilitate communication, planning and care delivery with informal carers
- Practitioners in independent practice as gate keepers and/or personal case and care managers
- Diversity-friendliness: recognition of the specific care needs of hard-to-reach groups
5.6 Specialised case or care management centres
This sub-theme refers to specialist centres or discrete groupings within organisations that specialise in case or care management. How do they organise approaches such as those in the list in order to promote seamless care? Examples include at least one of the following key issues:
- Access points (referral, counselling, one-stop-shops)
- Structures that facilitate multi-professional and inter-agency care planning and coordination
- Structures that are responsible for care planning and coordination between different kinds of services (as independent provider)
- Diversity-friendliness: recognition of the specific care needs of hard-to-reach groups
