Lessons from Denmark on caring for the elderly
1The growing number of elderly people in western countries makes it increasingly difficult to publicly finance substantive services for those who require care. At the same time the workforce dedicated to delivering care is diminishing. To address this dilemma we need to identify new ways of thinking and to discard myths about elderly care.
Twenty years ago a municipality of 5000 people in Denmark launched a three-year social experiment that eventually changed the field of elderly care (Wagner 1994). In 1984 the municipality of Skaevinge asked me to lead a project to revisit how it provided services to its 500 citizens age 65 and above. The municipality imposed two parameters. First, no employees were to experience salary cuts or to be laid off. Second, the budgetary allocation for elderly care was not to change. Two years later, Skaevinge had fully implemented one of the first integrated care initiatives in Denmark.
The Skaevinge project benefited from a concomitant national initiative to encourage local municipalities to assume increased responsibility for secondary health care services. However there was little practical information about how to implement changes at local levels.
We identified the following goals for the Skaevinge project:
- • to separate the issue of housing from that of care;
- • to introduce a 24 h care service giving citizens equal access to health care services regardless of whether they resided at home or in an institution;
- • to increase health personnel's understanding of holistic care;
- • to improve quality of life by giving citizens more influence over their care;
- • to introduce a preventive approach to care, and give early and individualized support with the aim of fewer hospital admissions;
- • to structure work through self-managed and interdisciplinary teams, with increased responsibility and broader competencies assigned to each team member; and
- • to integrate the health care areas into a common structure, thus achieving better use of collective financial and human resources.
These goals were largely achieved. The municipality reorganized its departmentalized care for older persons along the lines described above. The project introduced an active, prevention-orientated care policy for older persons.
To live in a traditional nursing home, elderly persons had been required to turn over their pension and 60% of their social income rate. In the 1990s a law was passed that prohibited construction of new nursing homes along traditional lines. Nursing homes were converted to health care centres, with private rented flats, offering 24 h integrated care service to elderly persons whether they reside at home or in an institution.
Through training programmes multidisciplinary personnel further developed professional competencies. Health personnel, elderly clients and their families were trained to understand the value of self-care. A multidisciplinary, citizen-led consultative group was established as an integral part of the system.
In 1994 we conducted an evaluation of the new elderly care delivery design and found overall satisfaction. During the 10 years of its existence, the number of people 65 years and above had risen by 30% without a concomitant rise in the cost of elderly service provision (Wagner 2001).
Today our knowledge of elderly care models has increased tremendously and there have been a number of similar initiatives in Denmark. However the lessons learnt from the Skaevinge project still hold true and can be summarized as follows:
• A great deal of education, understanding and effort is needed to initiate new ways of working and new attitudes towards the elderly. Communication across traditional disciplines and boundaries, such as municipalities and counties, is essential.
• All citizens should feel safe, have access to care and be able to contact a health care centre at any time. Citizens also should have access to guest facilities at a centre for temporary acute care as and when the need arises. Preventive visits should be performed by health care personnel on a regular basis or according to actual or perceived physical and emotional needs.
• It is best to dismantle the stringent division of disciplines through a slow process of restructuring. Multidisciplinary integration of autonomous groups with no formal leadership should emerge. In this way, effective and focused use of personnel becomes a requirement self-imposed by the teams.
• The citizen's voice is a basic component. Public authorities need to respect the citizen's right of choice, to use his/her own resources to the extent possible. To achieve useful and sustainable results, politicians must respect agreements that consider the employee's dedication and skills.
• Citizens have a right to manage their own funds. Free home-help services should be provided to citizens in institutions and in their own homes to offer flexible assistance and equal access to services no matter where the citizens live.
Results from the Skaevinge project have been presented in Europe, the United States, and Japan. Most recently the European Commission included the project's philosophy in its 5th framework programme: Quality of life and management of living resources. The PROCARE (Providing Integrated Health and Social Care for Older Persons Issues, Problems and Solutions) programme involves six European countries, with each presenting their most innovative approaches to elderly care (Colmorten et al. 2003).
I believe that we will increasingly see innovative approaches to organizing elderly care in response to changing demography. Each new initiative should have respect for the individual at its centre.
Lis Wagner, RN, HV, DrPH is an Associate Professor in the Department of Nursing Science at the Faculty of Health Sciences, Aarhus University in Denmark. She developed the Integrated Health Care System in Denmark in 1986 and since then has led several action research projects on elderly policy and care. She is a member of the Editorial Board of the International Nursing Review.