CARESS D2.1 - Europa EU [PDF]

Deliverable 2.1

ERASMUS+ 2015 SECTOR SKILLS ALLIANCES AGREEMENT No. 2015 – 3212 / 001 – 001 PROJECT No. 562634-EPP-1-2015-IT-EPPKA2-SSA

Deliverable Number: Title of Deliverable:

WP related to the Deliverable: Dissemination Level: (PU/PP/RE/CO)*: Nature of the Deliverable: (R/P/D/O)**: Actual Date of Delivery to the CEC:

2.1 Identification of the existing HHCPs, their role, Skill and competencies in elderly homecare sector in Europe WP2 PU O 31/05/2016

WP responsible: OMNIA Deliverable responsible: WP starting month WP ending month Partner Contributor(s):

SI4LIFE M1 M5 Liguria Region, Si4Life, Ggallery, VE-II, AGEPlatform, OMNIA, FNBE, Super, AYTO, UVA, SGGCYL, Pro. Vi Hub, ARS Partner Reviewer(s): OMNIA

*Dissemination Level: PU=Public CO=Confidential, only for members of the Alliance (including Commission Services). PP=Restricted to external subjects in confidential mode (including Commission Services) RE=Restricted to a group specified by the Alliance (including Commission Services).

**Nature of Deliverables: R=Report P=Prototype D=Demonstrator O=Other

Deliverable 2.1

1 ABSTRACT: The WP 2 is the general preparation work package, collecting and mapping background information for the design of the EU Framework (WP3), the design of national pilots (WP3) and their implementation (WP4 and WP5) and evaluation (WP6). Task 2.1, in particular, is aimed at the identification of the existing HHCPs, their role, skill and competencies in older adults homecare sector in Europe. This document reports the main results of T2.1 activities.

2 KEYWORDS: Homecare; Home Healthcare Practitioner; Older Adults; Competencies; Skills; Roles

3 LIST OF BENEFICIARIES (PP-RE)/PARTICIPANTS (PU-CO)*** Ben. No.

Beneficiary Name

Short Name

Country

Si4Life

Italy

Liguria Region

Italy

GGallery

Italy

1

Si4Life – Scienza e Impresa Insieme per Migliorare la Qualità della Vita s.c.r.l.

2

Regione Liguria

3

Ggallery s.r.l.

4

I.T.C. “Vittorio Emanuele II-Ruffini”

VE-II

Italy

5

AGE-Platform

AGE

Belgium

6

OMNIA

OMNIA

Finland

7

Finnish National Board of Education

FNBE

Finland

8

Super

SUPER

Finland

9

Ayuntamiento de Valladolid

AYTO

Spain

10

Universidad de Valladolid

UVA

Spain

11

Sociedad de Geriatría y Gerontología de Castilla y León

SGGCYL

Spain

12

Associazione Polo Tecnico Professionale Professioni Vita

Pro. Vi Hub

Italy

13

Azienda Regionale Sanitaria Ligure

ARS

Italy

14

Royal Cornwall Hospitals Trust

RCHT

UK

15

United Kingdom Homecare Association

UKHCA

UK

16

Nestor Primecare Services Ltd – Allied Healthcare

Allied Healthcare

UK

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*** List of Beneficiaries In case of dissemination level PU or CO please indicate all the partners involved in this Deliverable. In case of dissemination level PP please indicate the names of the other subject to whom the deliverable is devoted In case of dissemination level RE please indicate the restricted group of partners.

VERSION HISTORY VERSION PRIMARY AUTHORS

VERSION DESCRIPTION

DATE COMPLETED

0

SI4LIFE – Serena Alvino

Deliverable structure

19/02/2016

1

SI4LIFE – Serena Alvino, Daniele Musian, Barbara Mazzarino

First draft

15/05/2016

6

SI4LIFE – Serena Alvino, Daniele Musian, Barbara Mazzarino

Final version

31/05/2016

4 AUTHORS SECTION

AUTHORS

PARTNER TYPE

NAME OF PARTNER

INTRODUCTION

Serena Alvino

Full Partner

SI4LIFE

ELDER CARE IN EUROPE OVERVIEW

Philippe Seidel ; Borja Arrue

Full Partner

Age Platform

OLDER PERSONS HOMECARE IN ITALY

Isabella Roba

Associated Part.

ARS Liguria

Serena Alvino

Full Partner

SI4LIFE

Homecare for older people with disability

Fabio Marcenaro

Associated Part.

Pro.Vi Hub

Ilaria Scala Aldo Moretti

Report on questionnaires targeting Italian HHCPs

Barbara Mazzarino

Full Partner

SI4LIFE

Report on interviews targeting older adults experiencing homecare in Italy

Daniele Musian

Full Partner

SI4LIFE

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SECTION HHCP involved in older persons homecare service in Italy: roles and competences

AUTHORS

PARTNER TYPE

NAME OF PARTNER

PHYSIOTHERAPISTS: Luca Francini

AIFI Liguria

Supporting Partner

Elisa Pelosin

University of Genoa Physiotherapists Faculty

Supporting Partner

Daniela Garaventa

NURSES: Loredana Sasso Angela Bagnasco

PROFESSIONAL EDUCATORS: Nicola Titta Mario Saiano

University of Genoa - Nurses Faculty ANEP Associazione Nazionale Educatori Professionali

Supporting Partner

Supporting Partner

Davide Ceron Monica Miatto OVERVIEW ON THE OLDER PERSONS HOMECARE SERVICE IN SPAIN

MJ. Castro. MJ Cao. Leonor Pérez. José Mª Jiménez.

Full Partners

Uva-Nursing. VCC

SGCYL.

F.Javier Blanco. Lourdes Ausin. Alba Canteli. Virtudes Niño. Caridad Torrecilla. Carmen García de la Torre Azucena Jiménez.

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SECTION Report on primary data about homecare service in Spain

AUTHORS

PARTNER TYPE

MJ. Castro. MJ Cao. Leonor Pérez. José Mª Jiménez.

NAME OF PARTNER

Full Partners

Uva-Nursing. SGCYL. VCC, Uva-tech

Full Partners

Uva-Nursing. VCC

full partner

Omnia

full partner

Regione Liguria

full partner

AGE platform

F.Javier Blanco. Lourdes Ausin. Alba Canteli. Virtudes Niño. Caridad Torrecilla. Azucena Jiménez. Carmen García de la Torre J. Ignacio Asensio HHCP involved in older persons homecare service in spain: roles and competences

MJ. Castro. MJ Cao. Leonor Pérez. José Mª Jiménez.

SGCYL.

F.Javier Blanco. Lourdes Ausin. Alba Canteli. Virtudes Niño. Caridad Torrecilla. Carmen García de la Torre Azucena Jiménez. OLDER PERSONS HOMECARE IN FINLAND Overview on the older persons homecare service in Finland

Sirje Hassinen

Nina Kauppinen and Sanna Hosio

Report on primary data about homecare service in Finland HHCP involved in older persons homecare service in Finland: roles and competences

Sirje Hassinen, Asta Kaitila and Isabel Poikkimäki

OLDER PERSONS HOMECARE IN AUSTRIA

Michele Scarrone

OLDER PERSONS HOMECARE IN BELGIUM

Philippe Seidel ; Borja Arrue

Lucia Schifano

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SECTION

AUTHORS

PARTNER TYPE

NAME OF PARTNER

OLDER PERSONS HOMECARE IN BULGARIA

Serena Alvino

full partner

SI4LIFE

OLDER PERSONS HOMECARE IN CROATIA

Caridad Torrecilla Gómez

Full partner

VCC

Full partner

VCC

Full partner

VCC

Full partner

VCC

Azucena Jiménez López Introduction to older persons homecare service in Croatia

Caridad Torrecilla Gómez Azucena Jiménez López

HHCP involved in older persons homecare service in Croatia: roles and competences

Caridad Torrecilla Gómez

OLDER PERSONS HOMECARE IN CYPROS

Caridad Torrecilla Gómez

Azucena Jiménez López

Azucena Jiménez López OLDER PERSONS HOMECARE IN CEZ REPUBLIC

Barbara Mazzarino

full partner

SI4LIFE

OLDER PERSONS HOMECARE IN DENMARK

Paula Soivio

full partner

Super

OLDER PERSONS HOMECARE IN ESTONIA

Sirje Hassinen

full partner

Omnia

OLDER PERSONS HOMECARE IN FRANCE

Maria Rosaria Troiani

full partner

Vittorio Emanuele II

OLDER PERSONS HOMECARE IN GERMANY

Sirje Hassinen

full partner

Omnia

OLDER PERSONS HOMECARE IN GREECE

Daniele Musian

full partner

SI4LIFE

Benedetto Montanari

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SECTION

AUTHORS

PARTNER TYPE

NAME OF PARTNER

OLDER PERSONS HOMECARE IN HUNGARY

F.Javier Blanco Lourdes Ausin Alba Canteli Virtudes Niño

full partner

SGCYL

OLDER PERSONS HOMECARE IN Latvia

Sirje Hassinen

full partner

Omnia

OLDER PERSONS HOMECARE IN LITHUANIA

Sirje Hassinen

full partner

Omnia

OLDER PERSONS HOMECARE IN LUXEMBOURG

Paula Soivio

full partner

Super

OLDER PERSONS HOMECARE IN MALTA

Michele Scarrone

full partner

Regione Liguria

OLDER PERSONS HOMECARE IN NETHERLANDS

Michele Scarrone

full partner

Regione Liguria

OLDER PERSONS HOMECARE IN POLAND

Michele Scarrone

full partner

Regione Liguria

OLDER PERSONS HOMECARE IN PORTUGAL

F.Javier Blanco Lourdes Ausin Alba Canteli Virtudes Niño

full partner

SGCYL

OLDER PERSONS HOMECARE IN ROMANIA

F.Javier Blanco Lourdes Ausin Alba Canteli Virtudes Niño

full partner

SGCYL

OLDER PERSONS HOMECARE IN SLOVAKIA

Serena Alvino

full partner

SI4LIFE

OLDER PERSONS HOMECARE IN SWEDEN

Paula Soivio/

full partner

Super

Lucia Schifano

Lucia Schifano

Lucia Schifano

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SECTION

AUTHORS

OLDER PERSONS HOMECARE IN THE UNITED KINGDOM

PARTNER TYPE

Caridad Torrecilla Gómez

NAME OF PARTNER

Full partner

VCC

Azucena Jiménez López OLDER PERSONS HOMECARE IN NORWAY

Paula Soivio

full partner

Super

OLDER PERSONS HOMECARE IN ICELAND

Paula Soivio

full partner

Super

5 Sommario 1

ABSTRACT: .......................................................................................................................................................2

2

KEYWORDS: .....................................................................................................................................................2

3

LIST OF BENEFICIARIES (PP-RE)/PARTICIPANTS (PU-CO)*** ...........................................................................2

4

AUTHORS .........................................................................................................................................................3

6

INTRODUCTION: STRUCTURE AND AIMS OF THE DOCUMENT .....................................................................14

7

ELDERCARE IN EUROPE OVERVIEW ...............................................................................................................15

8

7.1

The challenges .......................................................................................................................................16

7.2

The responses ........................................................................................................................................17

OLDER PERSONS HOMECARE IN ITALY ..........................................................................................................18 8.1

Overview on the older persons homecare service in Italy ....................................................................18

8.1.1

The need and the supply for homecare ........................................................................................18

8.1.2

Health homecare and home nursing .............................................................................................22

8.1.3

Home help .....................................................................................................................................25

8.1.4

Private health and social homecare ..............................................................................................30

8.2

Homecare for older people with disabilities in Italy .............................................................................32

8.2.1

Legislation and recommendations on home care for persons with disability in Italy...................32

8.2.2 Responsibilities: Who is responsible for homecare (public/private sector, voluntary etc), who organize homecare? ......................................................................................................................................32 8.2.3

Actors in disabled people home care ............................................................................................32

8.2.4

Access and care delivery process ..................................................................................................33

8.2.5

Access model .................................................................................................................................33

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8.2.6

The financing of homecare service for persons with disability .....................................................33

8.2.7

Disabled people homecare challenges in Italy ..............................................................................34

8.3

Report on questionnaires targeting Italian HHCPs ................................................................................34

8.3.1

QUESTIONNAIRE SESSION 1: ACTUAL ACTIVITY AS A PROFESSIONAL...........................................35

8.3.2

QUESTIONNAIRE SESSION 2: TARGETED NEEDS AND COMPETENCES IN AN IDEAL HOMECARE .51

8.3.3

QUESTIONNAIRE SESSION 4: EVALUATION OF OLDER PERSONS’ NEEDS......................................57

8.3.4 QUESTIONNAIRE SESSION 5: ROLE OF THE HOMECARE PROVIDER ORGANIZATION IN THE DELIVERY OF THE SERVICE .............................................................................................................................57 8.4

Report on interviews targeting older adults experiencing homecare in Italy.......................................58

8.5

HHCP involved in older persons homecare service in Italy: roles and competences............................63

9

8.5.1

Nurses ............................................................................................................................................63

8.5.2

Physiotherapists ............................................................................................................................69

8.5.3

Psychologist ...................................................................................................................................77

8.5.4

Professional Educator ....................................................................................................................85

8.5.5

Occupational Therapist..................................................................................................................89

8.5.6

Social Health Operator (OSS) .........................................................................................................94

8.5.7

Homecare assistant / home helper ...............................................................................................98

8.5.8

Social Guardian ............................................................................................................................100

8.5.9

References ...................................................................................................................................102

OLDER PERSONS HOMECARE IN SPAIN .......................................................................................................104 9.1

Overview on the older persons homecare service in Spain ................................................................104

9.2

Report on primary data about homecare service in Spain..................................................................105

9.3

HHCP involved in older persons homecare service in Spain: roles and competences ........................109

9.3.1 10

REFERENCES.................................................................................................................................121

OLDER PERSONS HOMECARE IN FINLAND ..............................................................................................121

10.1

Overview on the older persons homecare service in Finland .............................................................121

10.1.1

Challenges of the Finnish home care...........................................................................................124

10.1.2

References ...................................................................................................................................125

10.2

Analysis of activities, skills and competences of home health care practitioners in Finland..............125

10.2.1

MATERIAL AND METHODS ..........................................................................................................125

10.2.2

RESULTS .......................................................................................................................................127

10.2.3

DISCUSSION .................................................................................................................................134

10.2.4

References ...................................................................................................................................137

10.3

Home care clients’ perceptions of quality of care and staff competence ..........................................138

10.3.1

Purpose of the study ...................................................................................................................138

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10.3.2

Material and methods .................................................................................................................139

10.3.3

Results .........................................................................................................................................140

CARE NEEDS AND PRIORITY OF THE CARE NEEDS .......................................................................................141 COMPETENCE AND SKILLS OF THE PRACTICAL NURSES ..............................................................................141 10.3.4

Discussion ....................................................................................................................................143

10.3.5

References ...................................................................................................................................144

10.4 11

HHCP involved in older persons homecare service in Finland: roles and competences .....................145 OLDER PERSONS HOMECARE IN AUSTRIA ...............................................................................................153

11.1

Introduction to older persons homecare service in Austria................................................................153

11.2

HHCP involved in older persons homecare service in Austria: roles and competences .....................160

11.2.1 12

References ...................................................................................................................................173

OLDER PERSONS HOMECARE IN BELGIUM..............................................................................................174

12.1

Introduction to older persons homecare service in Belgium ..............................................................174

12.2

HHCP involved in older persons homecare service in Belgium: roles and competences ...................175

12.2.1

Nursing auxiliary (‘aide soignant’) ...............................................................................................176

12.2.2

Nurses ..........................................................................................................................................177

12.2.3

Social Assistants ...........................................................................................................................179

12.2.4

Family helper (‘aide familiale’) ....................................................................................................180

12.3 13

Sources: ...............................................................................................................................................181 OLDER PERSONS HOMECARE IN BULGARIA ............................................................................................182

13.1

Introduction to older persons homecare service in Bulgaria ..............................................................182

13.1.1

Home healthcare in Bulgaria .......................................................................................................183

13.1.2

Social homecare in Bulgaria.........................................................................................................183

13.1.3

The role of NGOs and Bulgarian Red Cross .................................................................................184

13.1.4

“Home Care and Assistance Services towards Independent and Dignified Life” Project ...........185

13.2

HHCP involved in older persons homecare service in Bulgaria: roles and competences ...................186

13.2.1 14

References ...................................................................................................................................194

OLDER PERSONS HOMECARE IN CROATIA ..............................................................................................195

14.1

Introduction to older persons homecare service in Croatia ...............................................................195

14.2

HHCP involved in older persons homecare service in Croatia: roles and competences .....................197

14.2.1 15

References ...................................................................................................................................210

OLDER PERSONS HOMECARE IN CYPROS ................................................................................................210

15.1

Overview on the older persons homecare service in Cypros ..............................................................210

15.2

HHCP involved in older persons homecare service in Cypros: roles and competences .....................213

15.2.1

REFERENCES.................................................................................................................................225

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OLDER PERSONS HOMECARE IN CZECH REPUBLIC ..................................................................................226

16.1

Overview on the older persons homecare service in Czech Republic.................................................226

16.1.1

REGULATION ................................................................................................................................226

16.1.2

HOME-CARE PROVIDED SERVICES ...............................................................................................227

16.2

HHCP involved in older persons homecare service in Czech Republic: roles and competences ........228

16.2.1 17

References ...................................................................................................................................230

OLDER PERSONS HOMECARE IN DENMARK ............................................................................................230

17.1

Introduction to older persons homecare service in Denmark ............................................................230

Background information about dementia and home care services ............................................................230 17.2

HHCP involved in older persons homecare service in Denmark: roles and competences ..................233

17.2.1

Social- and health service assistants ...........................................................................................233

17.2.2

Social- and health service helper .................................................................................................234

17.2.3

References ...................................................................................................................................234

18

OLDER PERSONS HOMECARE IN ESTONIA...............................................................................................235

18.1

Introduction to older persons homecare service in Estonia ...............................................................235

18.2

HHCP involved in older persons homecare service in Estonia: roles and competences .....................238

18.2.1 19

References ...................................................................................................................................243

OLDER PERSONS HOMECARE IN FRANCE ................................................................................................244

19.1

Introduction to older persons homecare service in France ................................................................244

19.2

HHCP involved in older persons homecare service in France: roles and competences......................247

20

OLDER PERSONS HOMECARE IN GERMANY ............................................................................................254

20.1

Overview on the older persons homecare service in Germany ..........................................................254

20.2

HHCP involved in older persons homecare service in Germany: roles and competences..................258

20.2.1 21

References ...................................................................................................................................261

OLDER PERSONS HOMECARE IN GREECE ................................................................................................262

21.1

Overview on the older persons homecare service in Greece .............................................................262

21.1.1

The context of home care............................................................................................................262

21.2

HHCP involved in older persons homecare service in Greece: roles and competences .....................262

21.3

HHCP involved in older persons homecare service in Greece: roles and competences .....................264

22

OLDER PERSONS HOMECARE IN HUNGARY ............................................................................................270

22.1

Overview on the older persons homecare service in Hungary ...........................................................270

22.2

HHCP involved in older persons homecare service in Hungary: roles and competences ...................271

23

OLDER PERSONS HOMECARE IN IRELAND ...............................................................................................275

23.1

Introduction to older persons homecare service in Ireland ................................................................275

23.2

HHCP involved in older persons homecare service in Ireland: roles and competences .....................277

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23.2.1 24

References ...................................................................................................................................279

OLDER PERSONS HOMECARE IN LATVIA .................................................................................................280

24.1

Introduction to older persons homecare service in Latvia..................................................................280

24.2

HHCP involved in older persons homecare service in Latvia: roles and competences .......................283

24.2.1 25

References ...................................................................................................................................284

OLDER PERSONS HOMECARE IN LITHUANIA ...........................................................................................285

25.1

Introduction to older persons homecare service in Lithuania ............................................................285

25.2

HHCP involved in older persons homecare service in Lithuania: roles and competences..................288

25.2.1 26

References ...................................................................................................................................291

OLDER PERSONS HOMECARE IN LUXEMBOURG .....................................................................................292

Background information about dementia and home care services..............................................................292 Legislation relating to the provision of home care services..........................................................................292 Organisation and financing of home care services ........................................................................................292 Kinds of home care services available ...........................................................................................................293 26.1.1 27

References ...................................................................................................................................294

OLDER PERSONS HOMECARE IN MALTA .................................................................................................294

27.1

Introduction to older persons homecare service in Malta ..................................................................294

27.2

HHCP involved in older persons homecare service in Malta: roles and competences .......................301

27.2.1 28

References ...................................................................................................................................310

OLDER PERSONS HOMECARE IN NETHERLANDS .....................................................................................311

28.1

Introduction to older persons homecare service in Netherlands .......................................................311

28.1.1 28.2

References ...................................................................................................................................318

HHCP involved in older persons homecare service in Netherlands: roles and competences.............318

NURSES ........................................................................................................................................................319 29

OLDER PERSONS HOMECARE IN POLAND ...............................................................................................328

29.1

Introduction to older persons homecare service in Poland ................................................................328

29.2

HHCP involved in older persons homecare service in Poland: roles and competences .....................334

29.2.1 30

References ...................................................................................................................................337

OLDER PERSONS HOMECARE IN PORTUGAL ...........................................................................................338

30.1

Introduction to older persons homecare service in Portugal .............................................................338

30.1.1

Home of care continued health and support teams ...................................................................338

30.1.2

Home care service .......................................................................................................................339

30.2 31

HHCP involved in older persons homecare service in Portugal: roles and competences ...................340 OLDER PERSONS HOMECARE IN ROMANIA.............................................................................................343

31.1

Introduction to older persons homecare service in Romania .............................................................343

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HHCP involved in older persons homecare service in Romania: roles and competences ..................344 OLDER PERSONS HOMECARE IN SLOVAKIA .............................................................................................348

32.1

Overview on the older persons homecare service in Slovakia ............................................................348

32.1.1

Home healthcare in Slovakia .......................................................................................................349

32.1.2

Social homecare in Slovakia ........................................................................................................350

32.2

HHCP involved in older persons homecare service in Slovakia: roles and competences ...................350

32.2.1 33

References ...................................................................................................................................353

OLDER PERSONS HOMECARE IN SWEDEN...............................................................................................354 33.1.1

34

References ...................................................................................................................................356

OLDER PERSONS HOMECARE IN UK ........................................................................................................357

34.1

Introduction to older persons homecare service in UK.......................................................................357

34.2

HHCP involved in older persons homecare service in UK: roles and competences ............................360

35

OLDER PERSONS HOMECARE IN SWITZERLAND......................................................................................367

35.1

Introduction to older persons homecare service in Switzerland ........................................................367

35.2

HHCP involved in older persons homecare service in Switzerland: roles and competences..............369

35.2.1 36

OLDER PERSONS HOMECARE IN NORWAY ..............................................................................................372

36.1

Introduction to older persons homecare service in Norway...............................................................372

36.1.1 36.2 37

References ...................................................................................................................................371

References ...................................................................................................................................376

HHCP involved in older persons homecare service in Norway: roles and competences ....................376 OLDER PERSONS HOMECARE IN ICELAND ...............................................................................................377

37.1.1

References ...................................................................................................................................380

38

Annex 1: Questionnaire targeting HHCPs................................................................................................382

39

Annex 2: Structured interview to older adults ........................................................................................404

40 Annex 3: Finnish questionnaire targeting HHCPs: detailed percentages of knowledges, skills and competences (KSC) ..............................................................................................................................................411 40.1.1 ...........................................................................................................................................................414 40.1.2

General knowledge, skills and competences for procedures for monitoring healthy lifestyles .415

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6 INTRODUCTION: STRUCTURE AND AIMS OF THE DOCUMENT The WP 2 is the general preparation work package, collecting and mapping background information for the design of the EU Framework (WP3), the design of national pilots (WP3) and their implementation (WP4 and WP5) and evaluation (WP6). Task 2.1, in particular, is aimed at the identification of the existing HHCPs, their role, skill and competencies in older adults homecare sector in Europe. This document reports the main results of T2.1 activities. Each partner involved in the task has contributed to data collection and analysis. For all of the EU countries, partners have gathered secondary data by collecting available literature, statistics, available researches/projects results about the specific sector and other available documentation. Specific contacts have been set with professional associations in order to have a clearer picture of HHCP competencies in the particular country. EU project, such as EQUIP I and EQUIP II (funded under Lifelong Learning Programme), the ANCIEN Project (Assessing Needs of Care in European Nations, http://www.ancien-longtermcare.eu/) financed under the 7th EU Research Framework Programme, ELLAN Project (European Later Life Active Network http://ellan.savonia.fi/) funded with support from the Lifelong Learning Programme, and fundamental EU reports, such as -

Genet N, Boerma W, Kroneman M, Hutchinson A, Saltman RB. Home Care Across Europe: Current Structure and Future Challenges. Copenhagen: World Health Organization; 2012. Genet N, Boerma W, Kroneman M, Hutchinson A, Saltman RB. Home Care Across Europe: Case studies. Copenhagen: World Health Organization; 2012. World Health Organization. "WHO global strategy on people-centred and integrated health services: interim report." (2015).

have been taken as reference for the work. For Italy, Spain and Finland, which are the countries covered by the project partnership, primary data have been collected in addition to secondary ones. At local level, partners have worked for collecting primary data using 2 tools developed within the partnership: -

A Questionnaire targeting Home Healthcare Practitioners aimed at collecting data about their actual activities in homecare, their competencies and their attitude to lifelong learning (Annex I); A structured interview targeting older adults (over 65) aimed at collecting information about the homecare service they experienced and their needs (Annex II).

The Questionnaire targeting Home Healthcare Practitioners A shared English version of the questionnaire has been developed collaboratively within the partnership. It should be aimed to gather data useful for drawing down D2.1, D2.2 and D2.3. The questionnaire is composed by 7 sections: •

Section 0: is aimed at identifying the type of professional who is filling in the questionnaire;

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Section 1: is focused on HHCPs ACTUAL activity as a professional in homecare (what really happens when they provide their service at the older person’s own home); Section 2: is focused on an IDEAL situation, asking HHCPs to identify possible further older persons’ needs to address and possible further competencies necessary to target them; Section 3: (optional) is aimed at pointing out HHCPs opinion about their relationship with the user; Section 4: is aimed to understand how HHCPs evaluate older persons’ needs; Section 5: (optional) is focused on the role of the homecare provider organization in the delivery of the service; Section 6: is aimed at gathering data about educational and career pathways of the HHCPs; Section 7: is aimed to identify HHCPs attitude toward lifelong learning.

The shared version of the English questionnaire has been translated into Italian, Spanish and Finnish and some items has been customized according to contextual elements (eg. the list of possible HHCPs). Then partners implemented locally an online questionnaire using specific tools (eg. Limesurvey https://www.limesurvey.org/). The structured interview targeting older adults A shared English version of the structure (sections and items) has been developed collaboratively within the partnership. It should be aimed to gather data useful for drawing down D2.1, D2.2 and D2.3. Then, the Project Coordinator has developed a tool (to be printed on paper) that should be used by interviewers to provide questions and to take notes during the interviews. The tool has been translated into Italian, Spanish and Finnish in order to be used by local interviewers. The tool for structured interview is composed by xx sections: • • • •

Section 0: is aimed at gathering data about the older adult (age, sex, educational level, etc.) and about the homecare service he/she has experienced (asking to refer to only one service/experience). Section 1: is aimed at pointing out the older adult perception about the ACTUAL activities the HHCP (tasks, times, etc.) Section 2: is aimed at identifying the user needs that have been fulfilled by the service and needs that have been not fulfilled but they’d like to be fulfilled. Section 3: is focused on older adult opinion about abilities or characteristics that they consider fundamental for an homecare professional and about aspects they consider have improved their quality of life since the homecare professional assist them.

Interviews have been carried out both personally and by phone.

7 ELDERCARE IN EUROPE OVERVIEW Eldercare, often known as long-term care, can be defined as the support – both health and social care – provided to older people with a chronic illness and/or suffering a loss of autonomy, which can bring to dependency. A first basic distinction can be established between care delivered at home – home care – and care in institutions – both residential care and nursing homes. Current approaches to long-term care tend to challenge these categories and aim at creating new methods of care delivery that fully respect the dignity of the care recipient.

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As highlighted by Eurostat (see Figure 1), in 2009 about a half of European citizens aged 65 could expect to live less than half of their remaining years free of conditions affecting their autonomy, i.e. their ability to manage daily living activities.

Figure 1 Life expectancy compered to healthy years life

7.1 The challenges These numbers show that a significant proportion of older people will need care at some point of their lives. Moreover, the demographic trends will only increase the demand for eldercare. However, and despite the wide disparity between European countries, there is an overall shortage of qualified care professionals in Europe, as well as insufficient public provision of services and benefits to support those in need of care. Moreover, care is often delivered in an uncoordinated way, which has a negative impact on the quality of the care and the quality of life of the people in need of care. Another challenge relates to the availability of services that are affordable and accessible to all those in need. As shown in Figure 2, public spending in long-term care varies widely between European countries.

Figure 2 Public expenditure as % of GDP in European countries, all ages

Despite the relative generosity of long-term care systems of several European countries, overall 30% of citizens in Europe lack access to quality long-term care, according to the International Labour Organization (ILO), and affordability remains an issue given the only partial coverage of long-term care needs by social protection systems. While some countries developed a specific social insurance to cover long-term care needs, the right to receive care is weakly or not enforced in many European countries. 562634-EPP-1-2015-IT-EPPKA2-SSA

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The respect of the dignity of older people in need of care is a major challenge. Situations of neglect and abuse are still frequent, and elder abuse may be affecting up to 25% of older people. Abuse is sometimes related to the inability of informal carers – unpaid family members, neighbours or relatives caring for a person with longterm care needs – to cope with the stress and burden associated with caring responsibilities.

7.2 The responses Eldercare has traditionally focused on supporting those older people with a chronic condition and/or in loss of autonomy. While this remains the main mission of eldercare, new approaches have stressed the importance of developing services enabling prevention of the care needs linked to a loss of autonomy and rehabilitation of those who already suffered a condition limiting their autonomy. These new approaches, encouraged by European-level policies on social investment, are aligned with the objective of enabling active and healthy ageing in Europe as means to address demographic ageing. Developing quality person-centred eldercare also means integrating health and social care. Several European regions, often within European research projects, have developed pilots of integrated care, meaning the sharing of health and social information between care professionals and the development of shared decisionmaking and care planning. Integrating the different types of care that an individual receives, at home and/or in institutions/care facilities, proves to be a necessity in order to deliver the best possible care experience and optimise the use of resources. A rights-based approach to care, in full respect of the dignity and self-determination of the care recipient, has also been highlighted as the means to fight against elder abuse and neglect, against discrimination, and also as the basis to develop fully comprehensive long-term care systems that can offer affordable services to all those in need of care. Developing services to support informal carers, for instance through psychological support in respite facilities, has been highlighted as a necessary measure to accompany the development of eldercare services. As stated in the European Charter of Fundamental Rights, article 25, “the Union recognises and respects the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life”. Proactive and preventative policy approaches, such as the development of age-friendly environments, are meant to guarantee full participation of older people to social, economic and cultural life as long as possible, which should help prevent the need for eldercare.

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8 OLDER PERSONS HOMECARE IN ITALY 8.1 Overview on the older persons homecare service in Italy The healthcare policies that took place in Italy at the end of the 70s reflected all the developments that affected the matters related to healthcare. We basically transitioned from a situation where health used to mean ‘absence of any kind of disease’ to a more global concept of disease not only because it was seen as a “ global idea of physical, mental and social health according to the WHO, but also because of the close link between the health and social aspects that concern the same person and the significant role played by the community, the life, working, environmental, economic and cultural conditions one lives in. [Genoa 2008] The integration between policies and services plays a central role in the integration process that should involve all the services for people. [Maciocco & Scopetani, 2010] This process is still difficult though because it has developed in two separate directions one sanitary and the other one social. This gap has been made bigger by a combination between public, private and social players that play a part with different roles and importance. The basic laws on healthcare can be found in the main principles of the Republican Constitution (articles 2 and 3). These articles recognize and guarantee on one hand the fundamental human rights , while requiring ‘ the fulfillment of the mandatory duties of political economic and social solidarity ‘ , on the other hand it is stated the so-called principle of substantial equality which establishes the duty for the Republic to remove all economic and social obstacles that limit equality among citizens. Articles 32 and articles 38 focuses on the healthcare protection (art 32) and social assistance (art 38) but they immediately show that these two areas are on a different level: the first is seen as a fundamental right that must be granted to all people while the second is just a right granted to the people that do not have the basic means to live. A new law was issued in 2000 (Law 328) but it was strongly softened though with the Reformation of the Fifth Title of the constitution. Therefore the relation between the healthcare system and the social system as disciplined by law is not even. The healthcare system seems to be the most important aspect while the social system seems to be just a part that must be integrated with the first one. Furthermore, the basic levels of social services have not yet been defined at National level . This leads to a lack of funding by the State. Evidently this situation prevents a real integration between the healthcare and the sanitary systems resulting in a serious difficulty in managing all the human and material resources available at their best potential.

8.1.1 The need and the supply for homecare Italy is one of the countries in which the ageing society is most problematic. In Italy the population aging process is ongoing since several years, including the increasing of the old age index, reduction of the young population, increase of life expectancy. Due to these reasons the old age/young ratio, it is becoming alarming, reaching the 151,4 % in 2013 and 154,1 in 2014. At regional level Liguria is the one that has the higher old age index 239,5% as registered for years, followed by Friuli Venezia Giulia (196,1%) and Tuscany 190,1%.

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Figure 3: Italian population distributed by gender and by age in 1901, 1951, 2009 and 2030 [ISTAT, 2010]

Between 2014 and 2050, the old age dependency ratio1 is expected to increase from 54,6 (64.7 in Liguria) to an extreme 61 (less than 2 persons of working age for one elderly person), and the mean age will increase from 43 to 49 years [data 2014 - ISTAT]. The most intense growth, certainly compared to the rest of Europe, is in the age group of 85+ which will more than triple, up to 7.8% of the total population in 2050. Information available on the health status of Italians is contradictory. At age 65, men can expect to live further 18,9 years and women 22,6 years [data 2014 - ISTAT], both living longer than an average European at that age. However, the years lived in the absence of limitations in functioning/disability at that age falls down to 7.7 years for men and 7.1 for women [data 2013 – EUROSTAT]. Hence, the need for care may be relatively large. However, the share of persons over 65 reporting a long-standing illness or health problem is much lower (55.4%) than for Europeans (56.8% of women and 52.8% of men for the age group over 65 years; data 2013EUROSTAT). In Table 1 is represented the percentage of over 65 people with functional impairment distributed per region and impairment type. 1

The dependency ratio is obtained by comparing the non active population population (from 0 to 14 years of age and from 65 years of age and over) with the working population (from 15 to 64 years of age). This comparison which is usually multiplied per one-hundred indicates the demographic load on the active population. The figures that are over 50% indicate a generational imbalance.

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Figure 4 Demographic prevision 2007-2051 [ISTAT]

Region

Piemonte Valle d’Aosta Liguria Lombardia Trentino Alto Adige P.A. Bolzano P.A. Trento Veneto Friuli Venezia Giulia Emilia Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicilia Sardegna Italia

Types of functional limitations Confinement Limitations in daily life Limitations activities related to movement 6,3 9,0 8,8 7,2 9,1 9,1 7,4 9,9 8,4 7,9 9,5 7,7 4,1 10,4 7,3 3,3 9,4 6,2 5,0 11,4 8,3 7,6 12,4 9,3 9,7 11,2 9,0 7,2 12,3 9,2 8,5 9,8 10,5 8,3 15,3 11,8 10,0 13,7 9,0 9,5 12,2 9,6 8,8 13,1 7,6 9,4 12,2 11,9 12,9 16,2 12,4 14,3 18,7 13,4 9,3 11,2 8,4 10,9 15,3 11,5 12,8 16,8 13,8 10,6 17,0 13,8 9,4 12,8 10,2

Sight, hearing and speech limitations

Total %

3,7 3,3 2,9 3,5 4,8 4,0 5,5 4,6 4,6 4,7 4,6 6,2 5,2 5,7 6,2 4,9 7,4 6,6 7,6 7,1 6,3 5,8 5,2

14,7 14,4 15,0 15,7 15,3 14,9 15,8 18,7 17,4 17,9 17,6 21,3 19,2 19,4 19,2 20,6 25,2 26,9 19,7 22,8 25,5 25,4 19,8

Table 1 Percentage of over 65 people with functional impairment distributed by region and impairment type (year 2013) [ISTAT]

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In Italy the responsibility for home care is shared between the Regional government (Local Health Authority/Districts), which manages home health care, and the Local government (Municipality), which manages social homecare. The local governments accredit private providers of home help. Law 328/2000 stressed the importance of decentralizing the management of services (Ministry of Work and Social Policy, 2006) to for profit/ non-profit organizations, social cooperatives, volunteer organizations and other private organizations, through the authorization to deliver the services by Municipalities. Privately paid home social care is largely an informal market and often out of public regulations (Pesaresi, 2007a). Some attempts of a regularization of the private home aid market have been made in specific municipalities, such as online databases of professionals, but this is not managed at systematic level. Also private home nurses may be informal and unregulated. In order to find a professional nurse for care at home, clients must refer to the College of nurses (Ipasvi) to obtain a list of which professionals to contact (all enrolled on the Public Register of Nurses). There are concerns with the integration of social and home health care services. Only in some regions (mainly in the Centre-North of Italy) are there agreements between Municipalities and Local Health Authorities for an integrated provision (ADI) (Pesaresi 2007a, 2010). Table 2 shows the coverage, in percentage, of all the at-home sanitary services for the elderly and the athome social assistance services (SAD) for all the people who are over 65 years of age. Region Piemonte Valle d’Aosta Liguria Lombardia Trentino Alto Adige P.A. Bolzano P.A. Trento Veneto Friuli Venezia Giulia Emilia Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicilia Sardegna Italia

2005

2012

1,8 0,1 3,2 3,3 0,6 0,3 0,8 5,0 8,0 5,4 2,1 4,2 3,4 3,3 1,8 6,1 1,4 2,0 3,9 1,6 0,8 1,1 2,9

2,1 0,4 3,5 3,9 2,0 0,4 3,5 5,5 6,2 11,8 2,0 7,9 3,0 4,1 4,9 3,9 2,8 2,2 5,4 3,1 3,6 4,6 4,3

Number of hours per user per year 65+ 2012 15 37 28 18 n.d. n.d 13 10 6 18 22 22 25 21 34 81 29 37 43 20 30 36 21

Table 2: Homecare assistance coverage (percentage) for over 65 year old people [ISTAT, 2015; Ministry of Health, 2015]

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Regione Piemonte Valle d’Aosta Liguria Lombardia Trentino Alto Adige P.A. Bolzano P.A. Trento Veneto Friuli Venezia Giulia Emilia Romagna Toscana Umbria Marche Lazio Abruzzo Molise Campania Puglia Basilicata Calabria Sicilia Sardegna Italia

2005

2012

1,4 2,4 1,2 1,7 3,5 3,9 3,2 1,7 2,6 1,9 1,2 0,6 0,9 1,2 2,6 3,9 1,6 0,8 1,5 1,0 2,7 2,5 1,6

-0,6 2,9 -0,1 -0,3 0,8 0,9 0,7 -0,3 -0,3 -0,5 -0,5 -0,3 -0,2 -0,3 -1,3 -1,9 -0,5 -0,1 -0,2 = -0,1 = -0,3

Average expenditure per user 65+ - 2012 1.281 4.626 1.880 1.919 3.170 3.013 3.340 1.184 2.096 1.868 2.704 2.112 2.701 3.140 1.796 1.119 1.928 2.583 2.177 1.153 1.701 3.342 2.090

Table 3: Homecare assistance coverage (percentage) for over 65 year old people [ISTAT, 2015]

8.1.2 Health homecare and home nursing

The Ministry of Health develops the national legislation, national minimum standards and the criteria for using the National Health Fund. The National Health Service is financed by 95% through direct taxation (on income) and indirect taxation (on consumption). The National Health Fund (NHF) is divided among Regions and Local Health Authorities. The remaining costs are covered by revenues of Local Health Authorities and client copayment. The National Health Service guarantees to people that are not self-sufficient and are experiencing some difficulties and are sick or suffering from the consequences of a disease services and assistance at their homes. This services are called house care and they consist of a series of medical treatments to help the people involved in improving their life conditions. These homecare treatments are integrated with the social assistance services and the support of the family of the patient. They are generally granted by the Municipality where the person lives, after the completion of a procedure to check on the situation of the person in order to establish a socio-sanitary integrated project called ‘individual assistance project’ (IAP) The Region is responsible for planning and implementing services through the local health units. It is also in charge of defining the main organizational and managerial features of services, including control and supervision; also plans and organizes the professional training of the care personnel.

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The relevant legislation is the first Prime Ministerial Decree (Decree of the President of the Council of Ministers) of 29.11.2001 "" New territorial characterization home care and hospice work at home and in the Ministerial Decree of 17 December 2008 "Establishment of the information system the home care monitoring "The document “New definition of home nursing” in 2006 defined and updated the Essential Levels of health Assistance (LEA) [Ministry of Health, 2007], stating three categories of home nursing care: occasional, integrated and palliative. 1. Occasional homecare assistance: it is generally occasional but it can also be on a regular basis. A professional qualification is required for the staff that provides the assistance, in order to fulfill a specific medical need that does not require a multidisciplinary care plan. It is requested by the Doctor who is in charge of the patient and it is meant to fulfil a simple healthcare need for those patients that are not able to reach the outpatient services. 2. First and second level integrated homecare assistance: it is meant for those people that do not suffer from any serious disease but need constant assistance either for 5 (1st level) or 6 days (2nd level). The General Practitioner plays a central role at this stage. He is responsible for the healthcare procedures. The range of the medical services that are granted involves: medical, nursing, rehabilitation, social and welfare services. These services are part of a patient’s customized project that is the result of a multi-level evaluation process. 3. Third level integrated homecare treatments and homecare palliative treatments for terminally ill patients that need non-stop high-level assistance and highly qualified staff. These treatments are for: • Terminally ill patients (cancer-related or not); • Patients who suffer from neurological and degenerative or progressive degenerative diseases such as ALS or muscular dystrophy ; • Patients who need either artificial or parenteral nutrition or nutrition through a feeding tube; • Patients who need mechanical ventilation; • Patients in a permanent vegetative condition in a minimally consciuos state • Advanced and complicated stages of chronical diseases The document defines uniform eligibility criteria. Home nursing is needs-tested. The availability of informal carers is also taken into account. These services are free of charge for people with minimum income and aged over 65, and also for those with recognized chronic disabling diseases, for terminal cancer patients and during an intensive post-acute phase (protected discharge from hospital). Otherwise a ticket for co-payment is requested [Ministry of Health, 2010]. The national legislation must be implemented by the regional legislation through specific resolutions. Therefore each region has its own specific legislation. The indications set by the Administrative Law issued on the 29th November 2011 stem from the indications contained in the decree issued by the Regional council on the 20th March 2007 that establish the basic levels of homecare assistance and define the following aims to be reached by the Integrated System of homecare assistance in Liguria: • •

To provide adequate care to the people that have specific problems and are in need of homecare assistance in order to avoid any extra hospitalization or admissions to a nursing home To help those people who are no longer able to take care of themselves in order to let them live in their homes and help them to preserve their independence even if it is significantly reduced. 562634-EPP-1-2015-IT-EPPKA2-SSA

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•

To quickly discharge people from hospitals providing them with the assistance they may need in their homes. To help caregivers get the necessary training in order to give them the competences they need to carry out their duties independently. To improve the quality of life of those people that are no longer self- sufficient or are likely to lose their independence, in order to preserve the little independence they may have left.

• •

Homecare assistance is a kind of service that is part of the Essential Levels of Assistance System that guarantees the appropriate assistance to patients in whichever situation they may be, even the most difficult ones, or when they are either old or seriously sick or no longer self - sufficient. The request for any homecare treatment must be approved by the General Practitioner that must fill in an evaluation form about all the needs that the patient may have. Then the service schedules a visit to the patient in order to check his/her needs and the GP elaborates a customized assistance plan so the patient will be assisted by several members of the medical staff such as: doctors, nurses, physiotherapists, careers, specialists in order to reach all the goals set in the customized assistance plan. Table 4 reports data related to homecare treatments (PIC) in 2015 in Liguria (by Local Health Authorities) and Table 5 reports the public homecare treatments (PIC) in Italy. Asl Code 101

Asl description IMPERIESE

102

Cases

Patients over 65

Population over 65

3217

2.571

59562

SAVONESE

4417

3.116

80656

103

GENOVESE

8112

5.977

201477

104

CHIAVARESE

1886

1.268

41971

105

SPEZZINO

3446 21078

2.466

59662

15.398

443328

TOTAL

Table 4: public homecare treatments (PIC) in Liguria divided into the different Local Health Authorities in 2015

Region Code

Region Piemonte

Pic activated that must end in 2015 32911

Issued pic that end in 2015 27581

010 020

Valle d'Aosta

89

73

030

Lombardia

43775

42542

041

P.A. Bolzano

0

0

042

P.A. Trento

2683

1939

050

Veneto

4614

4582

060

Friuli-Venezia Giulia

4261

3678

070

Liguria

13433

12679

080

Emilia-Romagna

45183

45183

090

Toscana

27480

20364

100

Umbria

3028

2863

110

Marche

4797

4308

120

Lazio

0

0

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130

Abruzzo

4856

4516

140

Molise

2352

1991

150

Campania

0

0

160

Puglia

19919

17345

170

Basilicata

567

160

180

Calabria

3517

2867

190

Sicilia

1324

649

200

Sardegna

0

0

214789

193320

TOTAL

Table 5: public homecare cases in Italy divided by region in 2015 (PIC)

The main HHCPs (Home Health Care Practitioners) who are involved in Health Homecare in Italy are: •

•

• •

•

NURSES. In Italy there’s no specialization for nurses involved in homecare. After a three-year academic degree (EQF6), compliant with the “European agreement on the instruction and education of nurses”, Strasbourg, 25 October 1967 [Foreign and Commonwealth Office]2, nurses can provide public and private home nursing to older adults. PHYSIOTHERAPISTS. Physiotherapist is identified by Italian law as one of the health professions for rehabilitation. After a three-year academic degree (EQF6), physiotherapists can provide public and private homecare to older adults. PSYCHOLOGISTS. In Italy there’s no specialization for psychologist involved in homecare. PROFESSIONAL EDUCATOR. Professional Educators are health care professionals specialized in rehabilitation. Their work activities contribute to specific projects in the fields of education and rehabilitation to promote a balanced development, rehabilitation and social reintegration of physically or psychologically disadvantaged individuals, or people who are at risk of being socially marginalized. OCCUPATIONAL THERAPIST. Occupational therapists are identified by Italian law as one of the health professions for rehabilitation. After a three-year academic degree (EQF6), they can provide public and private homecare to older adults.

8.1.3 Home help The homecare assistance in Italy is managed at a local level. The Ministry of Work and Social Policy develops the national legislation, national minimum standards and the criteria for using the National Fund for Social Polices. Regions are responsible for planning and implementing home help services through the municipalities, monitor the implementation and the integration among the planned interventions (social and health services) and define the criteria for the authorisation, accreditation and monitoring of residential structures. A municipality define the local rules regarding the provision of home help, contract home help agencies, set prices and reimburses home help agencies (or grants voucher directly to the clients). Some regions (e.g. Lombardy) opted for other funding mechanisms and issued vouchers for entitled individuals, that can only be used for purchasing of specific services provided by providers authorized (accredited) by the public authority. Additionally, care allowances (by Municipalities or more rarely by Local Health Authorities) are used to pay family members for informal care. The client is free to spend the allowance as desired [Lamura & Principi, 2009]. 2

The agreement has been ratified in Italy with the law 795 – November 15th 1973

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The homecare assistance in Italy called SAD started in the 70s and it was aimed at taking care of the elderly in order to avoid their alienation from society. The first law that was issued to reform social services stated that the only authority that may handle such matters is the local municipality together with other institutions that work in the same area. The services that are provided are articulated in three groups: -

services at the patient’s home, services at the day care centres meals delivered at the patient’s location

The main aim of this kind of assistance is to promote and support a good quality of life for all the people who lost either permanently or temporarily their independence and let them live as long as possible in their homes avoiding their admission to a nursing home. As established by law n.328 in 2000 the local municipalities are in charge of all the assistance services for the citizens and they can either manage them individually or together with other nearby authorities according to the homecare assistance plans set by each region. Each local municipality checks the potential needs that people may have together with other local authorities such as comunità montana (an association created in the 70s in Italy that includes all the municipalities that are in the mountain areas and foothills) district authorities, local healthcare authorities call ASL in Italy and other kinds of associations. The Homecare Assistance Service (SAD) is a kind of service for people that are over 65 or for those people that find themselves in a psychophysical condition very similar to the one that an old person may experience in order to let them live in their house as long as possible. This kind of assistance has a double aim: it helps those who are no longer self-sufficient in their daily activities to stay and live in their homes in their usual social contest with the help of a social operator that goes to their house to help them and therefore avoiding or delaying their admission to a nursing home. These activities are related to: -

homecare assistance to help the elderly in their daily life the main services that are issued are linked to: personal care and hygiene, help in the daily running of their home, do the laundry and organize it, prepare the meals and help them in simple activities; the homecare assistance service is therefore aimed at improving the general wellness of a person in order to increase the number of the services that can be offered. To let the elderly live in their home safely as long as possible; keep or recover adequate levels of independence in order to avoid their admission to a nursing home; guarantee the cooperation with the National Healthcare Authority in order to offer an adequate assistance both at a social and medical level. To plan all the activities linking the homecare assistance services with the other services and resources in the territory; To improve and support the operators that help the elderly in order to guarantee a better quality of life; To promote and support the quality of life of the people that are no longer able to manage their family life; To improve the relationship between associations and charity organizations;

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To take care of all the needs that the elderly may have and therefore set up proper plans to fill their needs; To check the homecare assistance plan from time to time; The service is issued by the competent territorial services following a professional evaluation carried out by the Municipality. The people that are interested in getting assistance can fill in a form to ask for it. This form is available at the local municipality offices. They also request a medical record that must be filled in by the General Practitioner. The service can also be requested by the social careers in order to plan the discharge of the patients from the homecare treatment in case of some social problems related to the patient may occur.

Here are some data related to 2011 released on the ISTAT website in 2014 www.istat.it. They describe the number of users and the expenses faced per each patient. The data are divided according to the type of expenditure or region. ITEM OF EXPENDITURE

Expenditures

Average expense per user

Users

ACTIONS AND SERVICES Home assistance Socio-Assistance and home assistance Home assistance integrated with homecare services Neighborhood services Telecare Voucher, treatment voucher, socio-sanitary voucher Meals distribution and/or at-home laundry Other Home assistance total Support services Meals Social transportation Total of support services Total of actions anservices

345.478.102 68.182.920 8.731.668 11.549.986 100.343.429 29.991.163 7.191.295 571.468.563

169.580 75.347 12.484 65.230 62.956 41.815 22.195 -

2.037 905 699 177 1.594 717 324 -

2.596.241 23.613.668 26.209.909 740.081.530

4.095 125.711 -

634 188 -

Table 6: Elderly sector: users, expenses and expenses per user per each at-home service. Total in Italy - ISTAT Data (http://www.istat.it) in 2011, released in 2014 ITEMS OF EXPENDITURE

Expenditure

Users

Average expense per user

59.722.093 11.061.155 6.891.293 5.669.643 24.212.571 5.127.254 850.000

19.896 11.831 7.293 17.890 7.949 3.175 3.979

3.002 935 945 317 3.046 1.615 214

113.534.009

-

-

24.648 5.019.316

160 20.415

154 246

5.043.964

-

-

144.419.024

-

-

ACTIONS AND SERVICES Home assistance Home and social assistance Home assistance integrated with socio-sanitary services Neighborhood services Telecare Voucher, treatment voucher, socio-sanitary voucher Meals distribution and/or at-home laundry Other Home assistance (Total) Support Services Meals Social Transportation Total number of Support Services issued Total number of actions and services

Table 7: Elderly area: users, expenses and expenses per each users in the big municipalities (with a population of more than 250.000 inhabitants)per each at –home assistance service issued. ISTAT Data (http://www.istat.it) in 2011, released in 2014

REGIONS AND GEOGRAPHICAL ALLOCATION

Users

Expenditure

Average Expenditure per users

Piemonte

9.073

7.160.108

789

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REGIONS AND GEOGRAPHICAL ALLOCATION Valle d'Aosta/Vallée d’Aoste Liguria Lombardia Trentino-Alto Adige/Südtirol Bolzano/Bozen

Users

Expenditure

Average Expenditure per users

130

819.103

6.301 937

295

276.296

3.471

988.386

285

442

1.177.544

2.664

-

-

2.664

Trento

442

1.177.544

Veneto

39.025

16.490.246

423

541

1.939.530

3.585

Friuli - Venezia Giulia Emilia - Romagna

5.121

6.501.993

1.270

Toscana

6.018

10.191.412

1.693

Umbria

1.695

1.323.374

781

Marche Lazio Abruzzo Molise

441

1.165.598

2.643

3.996

7.792.903

1.950

659

1.486.874

2.256

9

17.109

1.901

Campania

1.878

5.015.867

2.671

Puglia

1.119

3.448.124

3.081

Basilicata

121

298.303

2.465

Calabria

494

388.135

786

Sicilia

542

998.005

1.841

Sardegna

277

704.010

2.542

Nord-ovest

12.969

9.243.893

713

Nord-est

45.129

26.109.313

579

Centro

12.150

20.473.287

1.685

4.280

10.654.412

2.489

819

1.702.015

2.078

75.347

68.182.920

905

Sud Isole ITALIA

Table 8: Home assistance integrated with sanitary services for the elderly: expenditure and average expenditure per user, region and geographical area – ISTAT Data (http://www.istat.it) in 2011, released in 2014 Municipalities covered by the service (percentage)

Territorial coverage index for the service (for 100 people)

Marker that indicates the amount of users who have been taken on (per 100 people)

Piemonte

96,2

97,9

0,9

Valle d'Aosta/Vallée d’Aoste

83,8

90,1

5,2

Liguria

98,3

99,2

1,1

REGIONS E GEOGRAPHICAL ALLOCATION

Lombardia

86,2

94,2

1,6

100,0

100,0

4,0

….

….

4,8

Trento

100,0

100,0

3,3

Veneto

94,0

97,2

1,4

100,0

100,0

2,3

Emilia - Romagna

88,2

91,4

1,6

Toscana

94,1

89,4

0,8

Umbria

85,9

75,5

0,3

Marche

79,5

87,9

0,7

Lazio

79,6

86,6

0,9

Abruzzo

96,1

90,9

1,6

Molise

73,5

80,2

2,2

Campania

89,1

71,8

1,2

Puglia

86,4

87,9

1,2

Trentino-Alto Adige/Südtirol Bolzano-Bozen (e)

Friuli - Venezia Giulia

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Municipalities covered by the service (percentage)

Territorial coverage index for the service (for 100 people)

Marker that indicates the amount of users who have been taken on (per 100 people)

Basilicata

80,2

86,6

1,4

Calabria

42,1

58,9

1,1

Sicilia

77,7

86,2

1,8

Sardegna

92,3

94,1

2,5

Nord-ovest

91,0

95,9

1,4

Nord-est

94,4

95,3

1,8

Centro

84,3

86,8

0,8

Sud

77,3

77,7

1,3

Isole

84,9

88,2

2,0

ITALIA

87,1

89,3

1,4

REGIONS E GEOGRAPHICAL ALLOCATION

Table 9: Home and social assistance for the elderly: territorial indicators ISTAT – Data in 2011 released in 2014 (http://www.istat.it)

REGIONS AND GEOGRAPHICAL ALLOCATION

Users

Expenditure

Piemonte

9.073

7.160.108

789

130

819.103

6.301 937

Valle d'Aosta/Vallée d’Aoste Liguria Lombardia

Average expenditure per user

295

276.296

3.471

988.386

285

442

1.177.544

2.664

Trentino-Alto Adige/Südtirol

-

-

-

Trento

442

1.177.544

2.664

Veneto

39.025

16.490.246

423

Bolzano/Bozen

Friuli - Venezia Giulia

541

1.939.530

3.585

Emilia - Romagna

5.121

6.501.993

1.270

Toscana

6.018

10.191.412

1.693

Umbria

1.695

1.323.374

781

Marche

441

1.165.598

2.643

3.996

7.792.903

1.950

659

1.486.874

2.256

Lazio Abruzzo Molise

9

17.109

1.901

Campania

1.878

5.015.867

2.671

Puglia

1.119

3.448.124

3.081

Basilicata

121

298.303

2.465

Calabria

494

388.135

786

Sicilia

542

998.005

1.841

Sardegna

277

704.010

2.542

Nord-ovest

12.969

9.243.893

713

Nord-est

45.129

26.109.313

579

Centro

12.150

20.473.287

1.685

4.280

10.654.412

2.489

819

1.702.015

2.078

75.347

68.182.920

905

Sud Isole ITALIA

Table 10: The home assistance integrated with sanitary services (in Italy called ADI ) for the elderly: users, expenditure and average expenditure per user, per region and geographical area ISTAT – Data (http://www.istat.it) in 2011, released in 2014

REGIONS AND GEOGRAPHICAL ALLOCATION

Municipalities covered by the service (percentage)

Service territorial coverage index (per 100 people)

Marker that indicates the amount of users who have been taken on (per 100 people)

93,4

92,7

0,7

1,4

31,7

0,8

91,9

95,4

0,6

Piemonte Valle d'Aosta/Vallée d’Aoste Liguria

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REGIONS AND GEOGRAPHICAL ALLOCATION

Municipalities covered by the service (percentage)

Lombardia

Service territorial coverage index (per 100 people)

Marker that indicates the amount of users who have been taken on (per 100 people)

66,4

70,9

0,5

Trentino-Alto Adige/Südtirol

100,0

100,0

0,2

Trento

100,0

100,0

0,4

Veneto

92,1

94,4

2,7

Friuli - Venezia Giulia

48,6

47,7

0,7

Emilia - Romagna

40,2

41,0

0,3

Toscana

29,3

36,2

0,3

Umbria

14,1

6,4

-0

Marche

54,0

48,6

0,2

Lazio

11,4

5,2

-0

Abruzzo

21,3

23,6

0,2

Molise

3,7

4,0

-0

Campania

5,8

8,0

0,1

Puglia

13,6

23,2

0,1

Basilicata

41,2

48,6

0,3

Calabria

10,5

7,6

-0

Sicilia

42,6

39,3

0,5

Sardegna

7,7

13,7

0,1

Nord-ovest

77,4

80,1

0,6

Nord-est

73,2

66,6

1,3

Centro

27,0

21,8

0,1

Sud

13,1

16,0

0,1

Isole

25,4

32,7

0,4

ITALIA

51,0

46,9

0,5

Table 11: Voucher, treatment voucher and socio-sanitary vouchers for the elderly: territorial indicators – ISTAT DATA in 2011 . (http://www.istat.it), released in 2014

The main HHCPs (Home Health Care Practitioners) who are involved in Social Homecare in Italy are: •

• •

SOCIAL-HEALTH OPERATOR. A social-health operator is a qualified professional whose job description centres on meeting the main needs of a patient, in a social or health care setting, by promoting the patient’s autonomy and welfare. This new figure was introduced by The State-Regions Conference of 22nd February 2001 HOMECARE ASSISTANT / HOME HELPER. The Homecare Assistant is the main figure who provides social homecare / home aid to older adults. SOCIAL CARERS. In Italy regions manages autonomously social services and in particular interventions for older adults in community. In some regions, specific figures manages services aimed at fostering older adults independent living, monitoring situations of fragility and empowering mental, physical and relational resources of the individual. This figure, who often attend a short course for being qualified, takes different names in different regions. In this report is presented the figure identified by Regione Liguria, the SOCIAL GUARDIAN.

8.1.4 Private health and social homecare The homecare assistance is a very important service in Italy but it is difficult to define with exception to those services that are outsourced by the local municipality authorities to other healthcare services according to law. Many families in Italy turn to homecare private assistance and they often do so illegally so it is extremely difficult to know the exact figures on this matter. We need to remember that often incentives are granted to the people that need them but it is still difficult to take account of the exact amount. 562634-EPP-1-2015-IT-EPPKA2-SSA

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As far as the home nursing is concerned we can say that about 9 million Italians pay to have a nurse in their homes. We can say that 8.7 million people turned to a private nurse in a year (17,2% of adult people) especially those who suffer from chronic diseases (2.8 million people) or those who are no longer selfsufficient. The majority of these people live in the North of Italy (25.8 %), while in the North East of Italy the percentage drops to 11.7%, 15.5% in the Centre and 15.4 in the South [Colicelli, 2015]. Based on the data collected by Censis (Centre for Social Investment Studies (www.censis.it), private spending on nursing care amounted to a total of 2.7 billion euro. The majority of the requested services were: injections (58.4%), perfusions, infusions and intravenous feeding (33.1%), general assistance (24.5%) medications and bandaging (24.4%) and night assistance (22.8%). 54% of this kind of assistance is unreported employment: 45% is completely unreported, 9% just for a small part. The economic crisis enables unreported employment because people can spend less. Everybody (40.7%) thinks that the nurses do not work with a regular contract because if they do so they must pay lots of taxes and therefore they can have less expenses (40.5%) and the patients can save some money. [Colicelli, 2015]. The demand for nursing assistance is even bigger because in Italy 0.1 people suffer from chronic disease, 5.6 million of them are old people and 3.1 million are no longer self-sufficient (1.5 million of them are no longer self-sufficient in a serious manner ) 4.2 million people turned to non-medical staff to ask for assistance in 2015. We usually turn to family carers (‘badanti’) or socio-sanitary operators for several reasons: because it is a reliable person that we know (42%) or because a professional nurse is too expensive (33.7%) and because people think that in many cases it not necessary to hire a nurse (31.5%) [Colicelli, 2015]. When family members take care of another member of the family who is no longer self - sufficient he/she takes care of all the medical needs this person may have such as pharmacological therapies (88.8%), giving injections (32.3%), bandaging and other medicaments (30.4%) and he/she is able to help whenever medical assistance is requested and deals with the catheter (6.2%). 51.5% of the people that can get assistance from a family member believe that he /she can also perform nursing duties and 30.6% believes he/she is able to intervene in case of an emergency. For 50.9 % of Italians ( 55.4 % among the elderly , who most need nursing care ) there are simple performances to be carried out such as injections or medications and therefore a nurse is not essential. This can result in inadequate performance and the risk related to a performance not carried out by professionals [Colicelli , 2015]. More than 2 million families ( 2.143.000 people) asked for monetary help to pay medical staff who most of the time (91%) has not been funded by social authorities. Moreover we need to take into account all those families that despite being in need do not ask for any help most of the time because they do not have the money to pay for it (12%, 2.9 million people). A family that needs full-time assistance (54 hours per week) needs to pay from 1.150 to 1.860 euros per month. [Merotta, 2016]. More than half of all the people working as a medical assistant in Italy were not Italian citizens in 2014: 459.000 out of 900.000. They are mainly women (81%) between 30 and 49 years old and they mainly come from: Ukraine (81%), Philippines (16%), Moldavia (11%) Peru (7%) and Sri Lanka (6%). They are mostly located in the North (36%) and the center (27%) of Italy, while in the North West and in the South the percentage significantly drops to 11% and 4% respectively.

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Domestic workers are mainly located in North West (36%) and in the centre (27%) of Italy where most people work full-time while in the North East they drop to 21%, to 11% in the South and 4% in the Islands where people have a kind of lifestyle that allows that. [IRS-Soleterre, 2015]. Most domestic workers take care of people that are over 75 years of age. Most of them live with the patient or with his family. Therefore domestic workers also get board and lodging. The patient often lives in a house that is too big for him/her and so to give domestic workers board and lodging is not an additional cost. Therefore this is the kind of assistance that is mostly requested by families, but sometimes they also ask for help just for a couple of hours or during the nighttime [Merotta, 2016]. There are many agencies to recruit domestic workers in Italy. Some of them demand domestic workers to have the ASA certification that certifies that a person is actually a domestic assistant or even the OSS certification that certifies that a person is a socio - sanitary operator. The regions and the local municipalities try to fight the unreported work phenomenon. The Ligurian region set a register for domestic workers in 2016 in order to define the workers profile and fix the balance between supply and demand, regulate the market and increase professionality. All the vouchers that the region will issue will be granted to the people that will hire registered workers.

8.2 Homecare for older people with disabilities in Italy 8.2.1 Legislation and recommendations on home care for persons with disability in Italy MINISTERIAL ACT: • DPCM 29/11/2001 LEA (BASIC ASSISTANCE LEVEL) REGIONAL LEGISLATION (Regione Liguria): • Regional Committee Resolution N. 337/2007 – Regional Basic Assistance level • Regional Committee Resolution N 446/2015 - Health and Social Services Integrated System • PSIR 2013/2015 (Health and Social Services Regional Integrated System) • Regional Law 12/20065 • Regional Law 41/2006

8.2.2 Responsibilities: Who is responsible for homecare (public/private sector, voluntary etc), who organize homecare? Homecare depends on public sector. The organization refers to health and social integrated system. Shown below how local levels work and the specific function they have: HEALTH AND SOCIAL DISTRICT is composed of: 1. HEALTH DISTRICT: health functions managed by Local Health Unit (Azienda Sanitaria Locale) 2. HEALTH AND SOCIAL AREA (District Unit; District Committee; health and social integrated Team): This area submits both health discrict and social disctrict. Local Health Unit and Municipality sign procedures in order to perform health and social functions. Different subjects are involved, disabled people too 3. SOCIAL DISTRICT: Social functions are managed by municipality

8.2.3 Actors in disabled people home care • • •

Social district manager Welfare worker Health and social integrated area coordinator 562634-EPP-1-2015-IT-EPPKA2-SSA

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• • • •

Educator and social animator Health care assistant or patient care assistant helps the patient move around, cleans patient, makes bed etc, no sticks, may take vitals, may administer drugs if prepared by a nurse Family carer supports people doing chores, about personal care, prepares meals and stimulates interests and socialization Psychologist

8.2.4 Access and care delivery process Access channel to health and social services network and person with a disability care process: In social district, in health district, in local health services for person with disability. Each access point is organized to meet people’s needs and manage it in an integrated manner Health and social integrated team evaluates the family situation with the family doctor/pediatrician collaboration Integrated team realizes a project that could be refers to other public services for people with disability Integrated team supervises and evaluates the projects District team for people with disability guarantees the respect of the uniqueness of the mission

8.2.5 Access model A Health and Social Integrated team for people with disability is organized by both health and social coordinator and it works alongside family doctor/ pediatrician. It is composed of local health unit staff, municipality staff, specialist concerning the specific disability, welfare worker, health care assistant, educator, psychologist, recovery therapist. It is necessary a care delivery process, needs assessments, individual assistance plan to subscribe the request. This model can allow an appropriate course of action. The access channel is a computerized single contact point.

8.2.6 The financing of homecare service for persons with disability Health budget is an economic, professional and human resources unit of measurement, aimed at a good social mode of operation as much as possible. In the details health budget is composed of health and social interventions. Benefits for careers are included in the health budget. Health budget could be provided both personal services and subsidy. The “life plan” (school and work inclusion – semi residential and residential - socialization and recreation – home care assistance) is a management tool able to realize social and health activities. It takes the form of an economic framework for the promotion of individual habilitation pathways Not self-sufficient and vulnerable people are the subjects of this kind of project. The welfare and rehabilitation plan must be defined on the basis of the evaluation system VILMA FABER based on ICF (CLASSIFICATION OF FUNCTIONING DISABILITY AND HEALTH) and supported by the bio-psycho-social regional dossier (FABER). Managing bodies and other accredited bodies are the network of health and social services components which contributes with the public service to design and manage the supply system (horizontal subsidiarity); Health Local Unit (ASL) and municipalities have the responsibility to refer people to suitable services and it has to look over the budget. Health budget could allow people with disability to remain in their own residence, to support independent living schemes, at home instead of home family care.

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TYPOLOGY

INDEPENDENT LIVING

LEGAL DISABILITY

Benefits for carers NOT REQUEST UP TO 25,000 EURO

MEDIA AND SEVERE DISABILITY Benefits for carers REQUEST UP TO 25,000 EURO

VERY SERIOUS DISABILITY I.A. ASSOCIATED TO DEPENDENT NO LIMIT ISEE

ISEE (EQUIVALENT ECONOMIC STATUS INDICATOR) COMPATIBILITY WITH RESID AND SEMIRESID SEMIRESID SERVICES ON NO COMPATIBILITY RESID / SEMIRESID SERVICES IN LOW ANY HEALTH INTENSITY SERVICES HEALTH INTENSITY MAX VALUE 1,200 EURO/ MONTH 500 EURO / MONTH 1.200 EURO / MONTH As is clear from the table, the aim is to coordinate the economic system sustainability and people with serious disabilities needs without taking in to account the Equivalent Economic Status Indicator (ISEE).

8.2.7 Disabled people homecare challenges in Italy One of the most important challenges is to design different way of living. People with disability, according to their own abilities, can experiment with independent living schemata, alone or in small groups, supervised by qualified personnel, however inside the house, not necessarily in a home care. It’s important taking in to account a specific training for the staff.

8.3 Report on questionnaires targeting Italian HHCPs The on-line questionnaire has been distributed through different channels, e.g. to professional nurses though the Regional Office of Health, to Physiotherapists though the National Association of Physiotherapists and so on. 214 subjects completed the questionnaire but only 190 have carried out an older adult homecare activity in the last 5 years. The distribution of answering practitioners is represented in Figure 5.

Figure 5: HHCPs answering the questionnaire

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Home care assistant/ home helper

Social Guardian

OSS – Social Health Operator

Physiotherapist

Nurse

The HHCPs distribution with respect to the contexts in which they perform their activities is represented in Table 12. This table has been extracted for the more significant group of practitioner with respect to the number of valid answers to the on-line questionnaire and interviews with end-users, i.e. Nurses, Physiotherapists, Social Health Operator, Social Guardian and Home care assistant/helper. The average age of the subjects seems to be homogenous between the categories, for this reason is not a relevant data for this analysis (median value between 40 and 45 years old).

Public institutional homecare provider 82,76% 27,14% 83,33% 10,00% 0,00% Private homecare provider 17,24% 7,14% 16,67% 70,00% 50,00% Freelance professional activity 0,00% 44,29% 0,00% 0,00% 25,00% Other 0,00% 21,43% 0,00% 20,00% 25,00% Table 12 Overview of the HCCPs italian context

8.3.1 QUESTIONNAIRE SESSION 1: ACTUAL ACTIVITY AS A PROFESSIONAL This section of the questionnaire has been focuses on actual activities as a professional in homecare, i.e. what really happens when HHCPs provide their service at the older person’s own home. 8.3.1.1 Activities normally carry out at the older person’s home Referring to the 5 selected Italian HHCPs, Figure 6 gives an overview about the activities normally carried out at the older person’s home. It is simple to highlight that all the figures reported equally that they perform the “evaluation of customer needs” and mainly the “Home Environment assessment” and the “evaluation of health condition”. It is also clear that, as expected, the activities closely related to the therapy are mainly performed by higher specialized figures (as nurses and physiotherapists) as well as the daily activities to support the old persons independence and their relationships (for details see the questionnaire Annex XXXX) are mainly performed by the other Italian HHCPs This result is also in line with the time each practitioners spend in the older person’s home, for example the companionship activity is mainly performed by Social Guardians and by the Home Care Assistant that have an average time spent in the houses longer than 1 our (see Figure 13).

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Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to excretory… monitoring healthy lifestyle prevention interventions

Nurse

Support to daily activities (shopping, going to a medical appointment, etc.)

Physiotherapist

house management and cooking

OSS

personal hygiene (bathing, grooming, etc.) education in health management and lifestyle

Social Guardian

intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs 0,00%

100,00%

200,00%

300,00%

400,00%

Figure 6 Overview of the answers provided at question “Which of the following activities do you normally carry out at the older person’s home” by the five selected Italian professions

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Nurse Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to excretory… monitoring healthy lifestyle prevention interventions Support to daily activities (shopping, going to a medical appointment, etc.) house management and cooking personal hygiene (bathing, grooming, etc.) education in health management and lifestyle intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs

0,00%

20,00%

40,00%

60,00%

80,00%

100,00%

Figure 7 Nurses answers on activites carried out

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Physiotherapist Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to… monitoring healthy lifestyle prevention interventions Support to daily activities (shopping, going to a medical appointment, etc.) house management and cooking personal hygiene (bathing, grooming, etc.) education in health management and lifestyle intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs 0,00%

20,00%

40,00%

60,00%

80,00%

100,00%

Figure 8 Phisioterapists answers on activites carried out

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OSS - SOCIAL HEALTH OPERATOR Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to… monitoring healthy lifestyle prevention interventions Support to daily activities (shopping, going to a medical appointment, etc.) house management and cooking personal hygiene (bathing, grooming, etc.) education in health management and lifestyle intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs 0,00%

10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00% 80,00% 90,00% 100,00%

Figure 9 Social health operator answers on activites carried out

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Social Guardian Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to… monitoring healthy lifestyle prevention interventions Support to daily activities (shopping, going to a medical appointment, etc.) house management and cooking personal hygiene (bathing, grooming, etc.) education in health management and lifestyle intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs 0,00%

20,00%

40,00%

60,00%

80,00%

100,00%

Figure 10 Social Guardian answers on activites carried out

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Home Care Assistant /Home Helper Other report of the activities conducted team meeting and contacts with the other professionals involved in older person’s assistance educational interventions for caregivers positioning and supporting mobility rehabilitation activities (walking, exercises, etc.) pharmacological treatment and homeostasis maintenance, performance relating to… monitoring healthy lifestyle prevention interventions Support to daily activities (shopping, going to a medical appointment, etc.) house management and cooking personal hygiene (bathing, grooming, etc.) education in health management and lifestyle intervention for a proper prescription and use of principals devices in home environment Home Environment assessment support and assistance in social relationships companionship personal assistance planning in-home health exams (e.g. taking blood sample) evaluation of health condition evaluation of customer needs 0,00%

20,00%

40,00%

60,00%

80,00%

100,00%

Figure 11 HomeCareAssistat/HomeHelper answers on activites carried out

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8.3.1.2 Performed activities overview The proposed question aims to identify for each practitioner which needs, from a list of 31 items, they normally address in their daily activity. The comparison between the main Italian practitioner answers is proposed in Figure 12. For each selected professions we highlight in specific paragraph the activities selected with a percentage higher than 70% by the subjects answering the questionnaire, and the those identified by a percentage of selection lower of 10%. NURSES Figure 7 reports all the answers of nurses, in tables here below are reported the activities performed only occasionally (Table 13) or more frequently (Table 14): Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...).

1,15%

Need of support and assistance in food management including preparation meals and purchase of foods.

2,30%

Need for a proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home.

3,45%

Need of support in mobility out of home .

4,60%

Table 13 Old persons’ needs less selected by Nurses as covered by their activity with the related percentage of selection

Need for protection of user privacy and intimacy . Need to a respectful treatment according to his/her dignity.

73,56% 77,01%

Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

78,16%

Need to be informed about your state of health and the available treatment and care options

78,16%

Specific care of urinary and fecal incontinence.

79,31%

Need to be supported and educated in proper positioning and postural changes to prevent physical disorders. Prevention of skin lesions through proper hygiene, postural changes and specific skin care.

80,46% 88,51%

Table 14 Old persons’ needs more selected by Nurses as those covered by their professionalo activity and the related percentage

PHYSIOTERAPISTS Figure 8 reports all the percentage distribution of physiotherapist’s answers, in tables below are reported the needs nor selected as those covered by their activities (Table 15) and those more frequently recognized as covered (Table 16): Need for a proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home

0,00%

Need of support and assistance in food management including preparation meals and purchase of foods

0,00%

Need of Support in adherence to treatment including preparing medication, reviewing medication consumpion. Need of support or interventions in managing meals in case of eating disorder or malnutrition

0,00% 1,43%

Specific care of urinary and fecal incontinence.

2,86%

Need of support and assistance to accomplish administrative procedures including those relating with health.

2,86%

Need to be supported in hygiene including shower or bath or oral hygiene

4,29%

Deliverable 2.1

Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). Need of support for the management of technological devices for home health monitoring

4,29%

Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

8,57%

7,14%

Table 15 Old persons’ needs less selected by Physiotherapists as covered by their activity with the related percentage of selection

Need to a respectful treatment according to his/her dignity Need of assistance for transfers and mobilization at home Need to be informed about your state of health and the available treatment and care options Need to feel safe and secure in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). Need to be supported and educated in proper positioning and postural changes to prevent physical disorders

70,00% 71,43% 72,86% 88,57% 92,86%

Table 16 Old persons’ needs more selected by Physiotherapists as those covered by their professionalo activity and the related percentage

OSS- SOCIAL HEALTH OPERATOR Figure 9 reports all the percentage distribution of OSS answers, here below are reported the activities not required by this practitioner category: Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...).

0,00%

Need of support for the management of technological devices for home health monitoring

8,33%

Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

8,33%

and the activities typical for this practitioner with the related percentage of selection: Need of assistance for transfers and mobilization at home

75,00%

Need to a respectful treatment according to his/her dignity

75,00%

Need to feel a deep respect regarding values (including religious beliefs and spiritual needs) Need to be supported in hygiene including shower or bath or oral hygiene Prevention of skin lesions through proper hygiene, postural changes and specific skin care.

75,00% 83,33% 83,33%

Need of support and rehabilitation in toilet habits.

83,33%

Need for protection of user privacy and intimacy.

83,33%

SOCIAL GUARDIAN Figure 10 reports all the social guardian answers, here below are reported the activities not required by this practitioner category: Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

0,00%

Specific care of urinary and fecal incontinence.

0,00%

Need to be supported in hygiene including shower or bath or oral hygiene Prevention of skin lesions through proper hygiene, postural changes and specific skin care.

0,00% 0,00%

Need of support and rehabilitation in toilet habits.

0,00%

and the most performed activities:

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Need of support and assistance to accomplish administrative procedures including those relating with health.

70,00%

Need of protection and promotion of the psychological and emotional welfare and protection Need to be self-determined and independent. Need to be informed about your state of health and the available treatment and care options

70,00% 80,00% 80,00%

Need to a respectful treatment according to his/her dignity

80,00%

Need of support in mobility out of home

90,00%

Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation.

90,00%

HOME CARE ASSISTANT /HOME HELPER Figure 11Figure 10 reports all the homecare assistant selection in percentage with respect to the activity they perform in the old adults, here below are reported the activities not required by this practitioner category: Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). Need of support for the management of technological devices for home health monitoring

0,00% 0,00%

Need of Support in adherence to treatment including preparing medication, reviewing medication consumpion. Need of support and assistance for effective communication.

0,00% 0,00%

Need of support and rehabilitation of cognitive abilities (memory, attention, orientation etc.)

0,00%

Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ... Need for protection of user privacy and intimacy

0,00% 0,00%

and the most performed activities: Need of assistance for dressing up and undressing Need of assistance for transfers and mobilization at home

75,00% 75,00%

Need of support and assistance in food management including preparation meals and purchase of foods

75,00%

Need of support and rehabilitation in toilet habits.

75,00%

Need to be supported in hygiene including shower or bath or oral hygiene

100,00%

Need for a proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home

100,00%

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Figure 12 Compared overview of the answers provided by participant to the question on needs addressed by their professional activity.

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8.3.1.3 Frequency of visits and time spent at the older person’s home The HHCPs has a similar frequency in visiting the old adult at home (Figure 14 How many times on average do you visit the same older person’s in a week) 2-3 times per week, instead the average time spent in the houses depends to their professional activities. Looking at Figure 13 it seems that the practitioners that carried out more clinical activities have a maximum of 1 hour instead the figure that mainly support old adults in daily activities have an higher average time. 100,00% 90,00% 80,00%

Nurse Phisioterapist OSS Social Guardian home care assistant /home helper

70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% Up to 15 minutes

From 15 to 30 From 30 min minutes to 1 hour

From 1 to 2 hours

From 2 to 4 hours

From 4 to 8 hours

Other

Figure 13 What is the average time ACTUALLY spent at the older person’s home in your daily activity

100,00% 90,00% 80,00%

Nurse

70,00%

Phisioterapist

60,00%

OSS

50,00% Social Guardian

40,00% 30,00% 20,00% 10,00% 0,00% Once

From 2 to 3 times

From 3 to 5 times

From 5 to 7 times

More than 7 times

Figure 14 How many times on average do you visit the same older person’s in a week

8.3.1.4 Professional competencies required by homecare In the question regarding skills and competences needed in home cares participant were asked to provide information about which competences are required in their work and at which level, in their opinion, they mastery them. They were also asked to indicate how they acquired the competences (education of practicing) A list of 42 competences has been proposed to the responders. To present results of Italian responders we highlight first the list of competences with the percentage of practitioner answering as required skills (Table 17 List of proposed competences and the related percentage of answers to the question about their requirement.), in light orange are highlighted the competences identify as “not required” by

Deliverable 2.1

Basic knowledge in medical assistance

home care assistant / home helper

Social Guardian

OSS

Required (A2)

86,21%

74,29%

25,00%

20,00%

0,00%

Not Required (A1)

12,64%

24,29%

75,00%

80,00%

100,00%

No answers Basic medical knowledge specifically related to my profession

Phisioterapist

IS THE COMPETENCE REQUIRED?

Nurse

the majority of all the 5 type of Italian practitioners, in the same way in light green are highlighted the item recognized as “required”. All the answers are reported in ANNEX XX .

1,15%

1,43%

0,00%

0,00%

0,00%

95,40%

84,29%

41,67%

10,00%

0,00%

Not Required (A1)

3,45%

14,29%

58,33%

90,00%

75,00%

No answers

1,15%

1,43%

0,00%

0,00%

25,00%

Required (A2)

Basics in anatomy and pathology

Required (A2) Not Required (A1) No answers

96,55% 3,45% 0,00%

94,29% 5,71% 0,00%

50,00% 41,67% 8,33%

10,00% 90,00% 0,00%

0,00% 100,00% 0,00%

Environmental and personal hygiene basic concepts

Required (A2)

91,95%

78,57%

75,00%

50,00%

75,00%

Not Required (A1)

6,90%

21,43%

25,00%

50,00%

25,00%

No answers Basics in home economics

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

18,39%

14,29%

33,33%

30,00%

75,00%

Not Required (A1)

79,31%

82,86%

66,67%

70,00%

25,00%

2,30%

2,86%

0,00%

0,00%

0,00%

No answers Basics in dietetic

Required (A2)

80,46%

42,86%

58,33%

10,00%

0,00%

Not Required (A1)

17,24%

57,14%

41,67%

90,00%

100,00%

No answers

2,30%

0,00%

0,00%

0,00%

0,00%

91,95%

94,29%

75,00%

80,00%

75,00%

Not Required (A1)

6,90%

5,71%

25,00%

20,00%

25,00%

No answers

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

81,61%

87,14%

66,67%

50,00%

25,00%

Not Required (A1)

16,09%

12,86%

33,33%

50,00%

75,00%

Required (A2) Basics in older person’s healthy lifestyles

Basic psychology elements

No answers Basics in domestic safety and prevention

2,30%

0,00%

0,00%

0,00%

0,00%

Required (A2)

66,67%

75,71%

66,67%

30,00%

50,00%

Not Required (A1)

32,18%

24,29%

33,33%

70,00%

50,00%

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

86,21%

75,71%

66,67%

80,00%

50,00%

Not Required (A1)

12,64%

24,29%

33,33%

20,00%

50,00%

No answers Basics in social-health services organizations and networks

No answers Knowledge about the main aids and devices for older and disabled people

1,15%

0,00%

0,00%

0,00%

0,00%

93,10%

98,57%

83,33%

50,00%

50,00%

Not Required (A1)

6,90%

1,43%

16,67%

50,00%

50,00%

No answers

0,00%

0,00%

0,00%

0,00%

0,00%

Required (A2)

Basic on the main characteristics of peoples with different levels of autonomy

Required (A2)

81,61%

82,86%

66,67%

20,00%

0,00%

Not Required (A1)

18,39%

14,29%

33,33%

80,00%

50,00%

0,00%

2,86%

0,00%

0,00%

50,00%

Basics in law and human rights frameworks

Required (A2)

57,47%

47,14%

50,00%

10,00%

0,00%

Not Required (A1)

41,38%

52,86%

41,67%

90,00%

100,00%

No answers

No answers Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.)

1,15%

0,00%

8,33%

0,00%

0,00%

94,25%

5,71%

25,00%

0,00%

0,00%

Not Required (A1)

5,75%

94,29%

66,67%

100,00%

100,00%

No answers

0,00%

0,00%

8,33%

0,00%

0,00%

Required (A2)

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Other specific basic medical procedures related to my profession Procedures for providing medical therapies

Required (A2)

90,80%

50,00%

16,67%

0,00%

0,00%

Not Required (A1)

5,75%

45,71%

83,33%

100,00%

100,00%

No answers

3,45%

4,29%

0,00%

0,00%

0,00%

Required (A2) Not Required (A1) No answers

Procedures for providing physical therapies

8,33%

0,00%

0,00%

0,00%

0,00%

0,00%

Not Required (A1)

52,87%

18,57%

100,00%

100,00%

100,00%

2,30%

1,43%

0,00%

0,00%

0,00%

Required (A2)

51,72%

44,29%

50,00%

10,00%

50,00%

Not Required (A1)

44,83%

55,71%

50,00%

90,00%

50,00%

3,45%

0,00%

0,00%

0,00%

0,00%

Required (A2)

81,61%

27,14%

83,33%

10,00%

75,00%

Not Required (A1)

17,24%

72,86%

16,67%

90,00%

25,00%

1,15%

0,00%

0,00%

0,00%

0,00%

89,66%

98,57%

75,00%

10,00%

75,00%

Not Required (A1)

9,20%

1,43%

25,00%

90,00%

25,00%

No answers

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

5,75%

0,00%

16,67%

10,00%

50,00%

93,10%

100,00%

75,00%

90,00%

50,00%

1,15%

0,00%

8,33%

0,00%

0,00%

Not Required (A1) Required (A2)

33,33%

4,29%

16,67%

0,00%

0,00%

Not Required (A1)

64,37%

94,29%

83,33%

100,00%

100,00%

2,30%

1,43%

0,00%

0,00%

0,00%

No answers Procedures for monitoring healthy lifestyles

Managing errands

Required (A2)

62,07%

48,57%

50,00%

60,00%

25,00%

Not Required (A1)

37,93%

51,43%

50,00%

40,00%

75,00%

No answers

0,00%

0,00%

0,00%

0,00%

0,00%

Required (A2)

3,45%

1,43%

25,00%

80,00%

50,00%

94,25%

98,57%

75,00%

20,00%

50,00%

2,30%

0,00%

0,00%

0,00%

0,00%

Not Required (A1) No answers

Usage of reporting and monitoring tools

Required (A2)

63,22%

32,86%

33,33%

60,00%

0,00%

Not Required (A1)

35,63%

67,14%

66,67%

40,00%

100,00%

No answers Procedures for fostering customers going out of home

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

37,93%

64,29%

50,00%

50,00%

50,00%

Not Required (A1)

60,92%

35,71%

50,00%

50,00%

50,00%

1,15%

0,00%

0,00%

0,00%

0,00%

No answers Fostering customers social and familiar relations

Required (A2)

57,47%

41,43%

66,67%

60,00%

50,00%

Not Required (A1)

42,53%

58,57%

33,33%

40,00%

50,00%

No answers Using ICT for social participation

0,00%

0,00%

0,00%

0,00%

0,00%

Required (A2)

26,44%

7,14%

41,67%

10,00%

0,00%

Not Required (A1)

73,56%

88,57%

58,33%

90,00%

100,00%

0,00%

4,29%

0,00%

0,00%

0,00%

No answers Using ICT for health status monitoring

Required (A2)

49,43%

5,71%

25,00%

10,00%

0,00%

Not Required (A1)

50,57%

90,00%

66,67%

90,00%

100,00%

0,00%

4,29%

8,33%

0,00%

0,00%

Required (A2)

75,86%

51,43%

75,00%

80,00%

0,00%

Not Required (A1)

24,14%

48,57%

25,00%

20,00%

50,00%

No answers Providing the customer with contextualized and personalized information about the network of services he/she can rely on Basic procedures in medical assistance (eg. make injection, provide drugs,

100,00%

1,43%

No answers Procedures for defining an eating plan

0,00%

100,00%

80,00%

Required (A2)

Cooking

0,00%

83,33%

1,15%

No answers Procedures for customer moving

8,33%

92,86%

44,83%

No answers Procedures for personal hygiene

5,71%

8,05%

Required (A2) No answers

Procedures for environmental hygiene

90,80%

No answers Required (A2) Not Required (A1)

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0,00%

0,00%

0,00%

0,00%

50,00%

97,70%

4,29%

16,67%

0,00%

0,00%

2,30%

95,71%

75,00%

100,00%

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change medications, etc.)

No answers

Competences for caring with dignity

0,00%

0,00%

8,33%

Required (A2)

83,91%

72,86%

Not Required (A1)

16,09%

25,71%

No answers Competences for managing conflicts

0,00%

0,00%

25,00%

41,67%

70,00%

25,00%

Not Required (A1)

54,02%

60,00%

58,33%

30,00%

75,00%

1,15%

0,00%

0,00%

0,00%

0,00%

89,66%

88,57%

66,67%

100,00%

50,00%

10,34%

11,43%

33,33%

0,00%

50,00%

0,00%

0,00%

0,00%

0,00%

0,00%

Required (A2)

45,98%

38,57%

33,33%

10,00%

0,00%

Not Required (A1)

51,72%

61,43%

58,33%

90,00%

100,00%

2,30%

0,00%

8,33%

0,00%

0,00%

91,95%

88,57%

75,00%

60,00%

0,00%

Not Required (A1)

8,05%

11,43%

25,00%

40,00%

100,00%

No answers

0,00%

0,00%

0,00%

0,00%

0,00%

Required (A2)

88,51%

82,86%

50,00%

70,00%

25,00%

Not Required (A1)

10,34%

17,14%

50,00%

30,00%

75,00%

1,15%

0,00%

0,00%

0,00%

0,00%

Required (A2)

77,01%

57,14%

8,33%

40,00%

25,00%

Not Required (A1)

21,84%

42,86%

83,33%

50,00%

75,00%

1,15%

0,00%

8,33%

10,00%

0,00%

No answers Required (A2)

58,62%

44,29%

16,67%

50,00%

25,00%

Not Required (A1)

41,38%

55,71%

75,00%

50,00%

75,00%

No answers Grief support

0,00%

0,00%

8,33%

0,00%

0,00%

Required (A2)

65,52%

24,29%

66,67%

50,00%

25,00%

Not Required (A1)

33,33%

72,86%

33,33%

50,00%

75,00%

1,15%

2,86%

0,00%

0,00%

0,00%

83,91%

50,00%

50,00%

30,00%

50,00%

16,09%

50,00%

41,67%

70,00%

50,00%

0,00%

0,00%

8,33%

0,00%

0,00%

Required (A2)

45,98%

55,71%

50,00%

50,00%

0,00%

Not Required (A1)

52,87%

42,86%

50,00%

50,00%

100,00%

No answers Required (A2) Competencies for terminal illness support Not Required (A1) No answers Competencies for supporting the customer in building up an independent living path

25,00%

1,43%

No answers

Competences for empowering the customer

50,00%

60,00%

40,00%

Required (A2)

Competences for evaluating customer mental health status

40,00%

25,00%

0,00%

No answers

Competences for evaluating customer needs and adapting the service

75,00%

44,83%

Required (A2) Competences for collaborating with other Not Required (A1) practitioners No answers

Competences for working in a group /equip /staff

0,00%

Required (A2) No answers

Competences for coordinating the work of other practitioners

0,00%

No answers 1,15% 1,43% 0,00% 0,00% 0,00% Table 17 List of proposed competences and the related percentage of answers to the question about their requirement.

Nurses and Physiotherapists indicated a majority of “required competences” with respect to those indicated as “not required competences”. Instead the other three figures have identified a major number of item recognized as “not required” for their specific activity (see Table 18 for an overview) Competences Required No required

Nurses

Physioterapists

OSS

31 11

21 20

18 19

Social Guardian 12 22

Home Care Assistant 5 24

Table 18 Practitioner identification of required /not required competences with respect to those presented in questionnaire

Responders evaluated also their ability in managing the competences and almost all the item recognized as required has been declared managed with high mastery. The same competences have been acquired, by the majority of the responders, both “attending a school, a training course or an academic course” then “working practice”. Only few items have a different behavior in the answers trend.

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Basic in dietetic has been recognize by OSS as a required competences but there is not a clear majority on how they mastery this competence (25% low mastery and 25% mean mastery). The item Basics in social-health services organizations and networks has been recognized as required competence by 4 type of Italian practitioner with respect to the 5 selected for the analysis of primary data, but there is no an homogenous perception of how they manage this competence for Nurses and Physioterapists (Table 19). The reason can be found in the acquisition of this competence. Competences Low Mastery Mean Mastery High Mastery

Nurses

Physioterapists

OSS

20,69% 32,18% 34,48%

24,29% 32,86% 21,43%

0,00% 0,00% 25,00% 30,00% 50,00% 70,00%

Social Guardian

Table 19 Overview of answers to how the practitioner master the competence “basic in social health services organizations and network”

The 44.83% of nurses acquired the competence during courses (with respect to a 33.33% that indicate not during courses) but at the same time the 80.46% of nurses declare to have learned such competence by working practice. Physiotherapists instead have a more structured answers to the acquisition of such competence, the 60% declared to have not learned it at school (vs 14.09% of yes) and the 67,14% indicate the working practice as competence acquisition method. For the same item we have a complete different situation in the answers provided by the Social Guardians. The majority of this responders indicate to have a high mastery of social-health services organizations and network competences at it has been acquired mainly by working practice (80% of positive answers) and nor in official training courses. Basics in law and human rights frameworks competence for Nurses has a medium/low level of mastery (29,89% medium and 26,44 low) even if it has been acquired by the majority of the responders both at official courses and working practice. Social Guardians differences their answers from the general trend also for other 6 competences. Those competences are recognized as required, but in all the cases the acquisition of these competences happens mainly by working practice instead of school or courses. Table 20 gives an overview on the percentage of positive answers to the questions 1.5 of the 6 competences. Required competence Competences Procedures for monitoring healthy lifestyles Basics in older person’s healthy lifestyles Managing errands Usage of reporting and monitoring tools Fostering customers social and familiar relations Providing the customer with contextualized and personalized information about the network of services he/she can rely on

Acquired working practice

by

Acquired attending courses…

60%

70%

30%

80% 80% 60%

90% 70% 60%

50% 20% 30%

60%

70%

30%

80%

70%

30%

by

Table 20 Comparison between the answers of social guardians to the questions “is the competencies required to perform the activity”, “how do you master these competencies” and “how did you acquire these competences” for 5 Competences that hve been acquired mainly working practice.

Similar to such behavior on Social Guardians’ answers above described there is the Physiotherapists approach to the Procedures for fostering customers going out of home and to Competences for caring with dignity. In 562634-EPP-1-2015-IT-EPPKA2-SSA

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this case the competence is recognize to be a required competence acquired by working practice by the 64,29% of responders for the first item and 58.57% for the second, with respect to a 20% - 24% of them who declared to have acquired such competence during formal training. Basics in domestic safety and prevention is another item that present a discrepancy in the answers distribution. It has been recognized as “not required competence” by the majority of the Social Guardians responders (70%) at the same time the 60% of such figures declared a high level of mastery for this competence, even if it has been acquired only working by practice. 8.3.1.5 Additional competencies required to perform the activities carry out by the practitioner This question has been designed to give the possibility to integrate the previous list of competences with specific items. The distribution in percentage of subject who identifies the need to integrate the list is represented in Table 21. There are other competences…? YES NO

Nurses

Physiotherapists

OSS

Social Guardian

Home Care Assistant

4,60% 95,40%

15,71% 84,29%

0,00% 100,00%

10,00% 90,00%

0,00% 100,00%

Table 21 Answers to question “Are there other competencies that you think are required to perform the activities you actually carry out and to address the needs you actually target in addition to those listed below”

Even if from Table 18 Nurses and Physiotherapists have found a majority of required items, few of them suggest other competences required for performing their activity; on contrary OSS, Social Guardian and Home Care Assistant seems to be satisfied by the first list. In the free text (question 1.6b) some of the Nurses and Physiotherapists involved in the questionnaire suggested commonly as required competence on relating with familiars and other informal caregivers.

8.3.2 QUESTIONNAIRE SESSION 2: TARGETED NEEDS AND COMPETENCES IN AN IDEAL HOMECARE This section of the questionnaire we will focus on an IDEAL situation, asking to responders to identify possible further older persons’ needs to address and possible further competencies necessary to target them. In Table 22 there is the resume of the answers to the first question aiming to identify if there are additional needs

YES NO

Nurses

Physiotherapists

OSS

Social Guardian

home care assistant / home helper

9,20% 90,80%

18,57% 81,43%

33,33% 66,67%

0,00% 100,00%

0,00% 100,00%

Table 22 Answers to question “Do you think that there are some users’ needs that should be addressed by your activity AS SPECIFIC PROFESSIONAL in addition to those selected above”

Subjects answering positively to this question have the possibility to select, from a list of 31 needs, those that can be fulfilled by their activity. Figure 15 gives the overview of such selection. Few nurses have answered positively to the previous question, and this is coherent with the distribution of positive answers with respect to the competences identified has required in the previous section (see Table 18). From the suggested needs provided, Table 23 represent the nurses choices selected with a greater percentage. Need to be supported in hygiene including shower or bath or oral hygiene 562634-EPP-1-2015-IT-EPPKA2-SSA

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Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. Need of support in compliance with non pharmachological treatment including active and health lifestyle such as prescribed diet, food intake control, physical excercises

5,75% 5,75%

Table 23 Needs selected by nurses

Table 24 instead reasume the needs identified by Physiotherapists with a higher percentage as well as Table 25 reasume the OSS choises. Specific care of urinary and fecal incontinence. Need of support and assistance to accomplish administrative procedures including those relating with health. Need of support in mobility out of home Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. Need to be supported in the self-management of his/her physical health. Need to be supported in the self-management of his/her mental health Need to feel safe and secure in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). Need of support in compliance with non pharmachological treatment including active and health lifestyle such as prescribed diet, food intake control, physical excercises Need of support and rehabilitation of cognitive abilities (memory, attention, orientation etc.) Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ... Need to a respectful treatment according to his/her dignity Need to be informed about your state of health and the available treatment and care options

5,71% 5,71% 11,43% 11,43% 5,71% 5,71% 7,14% 5,71% 5,71% 5,71% 5,71% 5,71%

Table 24 List of needs selected by Physiotherapists with an higher percentage

Specific care of urinary and fecal incontinence. Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). Need of support and assistance to accomplish administrative procedures including those relating with health. Need of support for the management of technological devices for home health monitoring Need of support in mobility out of home Need of protection and promotion of the psychological and emotional welfare and protection Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. Need to be supported in the self-management of his/her mental health Need to be supported and educated in proper positioning and postural changes to prevent physical disorders Need to feel safe and secure in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). Need of Support in adherence to treatment including preparing medication, reviewing medication consumpion. Need of support or interventions in managing meals in case of eating disorder or malnutrition Need of support and assistance for effective communication. Need to be informed about your state of health and the available treatment and care options

8,33% 25,00% 8,33% 8,33% 16,67% 16,67% 8,33% 8,33% 8,33% 8,33% 16,67% 16,67% 8,33% 8,33%

Table 25 List of needs selected by OSS with an higher percentage

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Figure 15 Comparison between the practitioners selection of needs they currently don’t address but they perceive the need.

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to the participants that identified the possibility to address further needs of the old people, were asked also to indicate from a list of 42 competences (the same of question 1.5) which of them are necessary for addressing such needs. Nurses indicate almost all the competences as required. Instead physiotherapists identified with a clear majority only 11 competences. The third Italian category of HHCPs, i.e. OSS, have not a clear opinion between required or not required for 61.9% of the proposed competences ( i.e. distribution of 50% of the answers between required and not required), instead for the others competences they clearly defined them as not required, Table 26 reassumes this aspect. Competences Required No required Not a defined majority

Nurses 39

Physiotherapists 11

OSS 0

3

31

14

0

0

26

Table 26 Number of proposed competences selected by the majority of the responders as required or not required. When the distribution between the two asswers is 50% it has been counted as “not a defined majority”.

Also in this case the trend of answers of the Nurses is homogenous, the majority of them perceived the level of how they master the competence Average or High level. The competences have been acquired attending a school, training courses or academic courses and have been improved during working practice. The only competence that deviates from this trend is the item Competencies for terminal illness support, for it there is not a defined majority identifying if this competence has been acquired attending at courses or not (50% equally distributed). More over this competence has no a clear majority on the question related to how they manage it, in fact 25% answered low mastery, 25% answered average mastery, 37,5% answered high mastery and 12,5% preferred to avoid answering. In Table 27 are reported the 11 competences identified by physiotherapists as required as well as they level of mastery and how they acquired them. In most of the cases the subjects preferred to not answering to the questions related to how they manage the competence and on how they acquired them. The main reason can be the fact that such competences have been declared to be required for satisfying additional needs to those already covered by their activity. Subjects presenting an answer, for example, on how they master the competences declare to have a high level of mastery.

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COMPETENCE

Basic knowledge in medical assistance

Basic medical knowledge specifically related to my profession

Basics in anatomy and pathology

Basics in older person’s healthy lifestyles

Basics in domestic safety and prevention

Basics in social-health services organizations and networks

Knowledge about the main aids and devices for older and disabled people Basic on the main characteristics of peoples with different levels of autonomy

IS THE COMPETENCE REQUIRED? Required NotRequired

53,85% 46,15% 0,00%

Required NotRequired

69,23% 30,77%

Required NotRequired

69,23% 30,77%

Required NotRequired

69,23% 30,77%

Required NotRequired

53,85% 46,15%

Required NotRequired

53,85% 46,15%

Required NotRequired

69,23% 30,77%

Required NotRequired

53,85% 46,15%

SELF-EVALUATE THE LEVEL YOU MASTER THE COMPETENCE No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery

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53,85% 7,69% 15,38% 23,08% 38,46% 0,00% 23,08% 38,46% 38,46% 0,00% 23,08% 38,46% 38,46% 7,69% 23,08% 30,77% 53,85% 7,69% 0,00% 38,46% 46,15% 15,38% 23,08% 15,38% 38,46% 0,00% 7,69% 53,85% 46,15% 0,00% 7,69% 46,15%

COMPETENCE ACQUIRED ATTENDING A SCHOOL, A TRAINING COURSE OR AN ACADEMIC COURSE No answer 53,85% No 0,00% Yes 46,15%

No answer No Yes

69,23% 7,69% 23,08%

No answer No Yes

38,46% 0,00% 61,54%

No answer No Yes

46,15% 23,08% 30,77%

No answer No Yes

38,46% 0,00% 61,54%

No answer No Yes

46,15% 30,77% 23,08%

No answer No Yes

53,85% 7,69% 38,46%

No answer No Yes

38,46% 15,38% 46,15%

No answer No Yes

69,23% 7,69% 23,08%

No answer No Yes

61,54% 7,69% 30,77%

No answer No Yes

53,85% 23,08% 23,08%

No answer No Yes

46,15% 15,38% 38,46%

No answer No Yes

38,46% 7,69% 53,85%

No answer No Yes

38,46% 15,38% 46,15%

No answer No Yes

46,15% 7,69% 46,15%

No answer No Yes

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COMPETENCE

Procedures for providing physical therapies

Procedures for customer moving

Procedures for fostering customers going out of home

IS THE COMPETENCE REQUIRED? Required NotRequired

69,23% 30,77%

Required NotRequired

61,54% 38,46%

Required NotRequired

53,85% 46,15%

SELF-EVALUATE THE LEVEL YOU MASTER THE COMPETENCE No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery No answer Low Mastery Average Mastery High Mastery

38,46% 0,00% 15,38% 46,15% 46,15% 0,00% 7,69% 46,15% 53,85% 7,69% 15,38% 23,08%

COMPETENCE ACQUIRED ATTENDING A SCHOOL, A TRAINING COURSE OR AN ACADEMIC COURSE No answer 38,46% No 0,00% Yes 61,54%

No answer No Yes

46,15% 23,08% 30,77%

No answer No Yes

46,15% 0,00% 53,85%

No answer No Yes

53,85% 7,69% 38,46%

No answer No Yes

61,54% 15,38% 23,08%

No answer No Yes

53,85% 15,38% 30,77%

COMPETENCE ACQUIRED BY WORKING PRACTICE

Table 27 Required additional competences identified by physiotherapists with the related level of mastery and how they acquired them.

The other two questions give the possibility to indicate other competences with respect to the presented list but in this case nobody declared that other competences are required.

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8.3.3 QUESTIONNAIRE SESSION 4: EVALUATION OF OLDER PERSONS’ NEEDS The proposed questions are filtered in function on the answers to section 0 (see Table 12) so no all the selected categories of Italian HHCPs has answered to all the questions. All the selected category work for homecare provider and the majority of these responders normally participate in the definition of the older person’s needs and participate in the definition of a personalized homecare plan with the exception of Social Guardian. The freelance practitioner of Physiotherapists and Social Guardian has declare that formalize in a sheet, a chart or a report both the initial evaluation of older person’s need then the homecare plan. Instead the freelance representatives of the Home Care Assistant declare to not formalize any evaluation of old adult or homecare plan, as expected by their role. All the 5 categories of Italian HHCPs normally evaluate in itinere elderly needs and, when possible, they refine the homecare plan according to changing situations (85% in average). At the same time the practitioner answered with a big majority (average of 81%) that they set their intervention, in the homecare plan, in a more general personalized path for independent life and dignity, with proper competences following the 76.83% of responders.

8.3.4 QUESTIONNAIRE SESSION 5: ROLE OF THE HOMECARE PROVIDER ORGANIZATION IN THE DELIVERY OF THE SERVICE This part of the questionnaire is conditioned to the context of the practitioner as described in Table 12, in particular only to whom working for an home care provider, either private or public. The majority of HHCPs had detailed operative guidelines but in any case they perceived a good level of autonomy with respect to such indications. Table 28 and Table 29 details the distribution of the answers.

OSS

home care assistant / home helper

Nurse

Yes

79,31%

58,33% 100,00%

87,50%

100,00%

No

20,69%

41,67%

0,00%

12,50%

0,00%

0,00%

0,00%

0,00%

0,00%

0,00%

No answers

Phisioterapist

Social Guardian

Question no 5.1 A

Table 28 Distribution of answers to the question “Does your organization provide you with detailed operative guidelines?”

Nurse Question No. 5.1. b 1 (1) 2 (2) 3 (3) 4 (4) 5 (5) Mean Standard deviation

0,00% 3,45% 18,39% 44,83% 12,64% 3,84 0,74

Phisioterapist

Social home care assistant / Guardian home helper

OSS

0,00% 0,00% 4,29% 12,86% 2,86% 3,93 0,62

25,00% 0,00% 33,33% 41,67% 0,00% 2,92 1,24

0,00% 0,00% 10,00% 40,00% 20,00% 4,14 0,69

0,00% 0,00% 25,00% 25,00% 0,00% 3,5 0,71

Table 29 Distribution of answers to the question “If yes, what is the level of your autonomy with respect to the guidelines? Please select a value from 1=no autonomy to 5=complete autonomy”

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8.4 Report on interviews targeting older adults experiencing homecare in Italy The total number of older adults interviewed on the experience of homecare services are 28. 12 (43%) of respondents answered in relation to the provision of homecare services from Homecare assistant, 9 (32%) referred to the provision of a homecare services from Social guardian, 6 referring to the provision of a homecare services from rehabilitation staff and 1 (4%) referring to the homecare services provided by an educator(Figure 16. HHCP professionals whose older adults). The total No of subjects interviewed are 28, 9 men and 19 women All the subjects interviewed were over 65. Figure 16. HHCP professionals whose older adults interview referring to.

Social guardian

21% 32% 4%

Home care assistant/Home Helper Educator

Rehabilitation staff

43%

Figure 17 Social guardian services reported by older adults show the profiles of the activities of the different HHCP (social guardian, Homecare assistant and Rehabilitation staff) reported by older interviewed. The results show that older adults receiving homecare services from Social Gaurdians report mainly activities related to: support and assistance in social relationships (100%), companionship (88.9%) and support in the implementation of activities of daily living (88.9%). Comparing the profile arising from these dat with the one described by the Social guardian responding on the same question in the Questionnaire, we can appreciate that there is a is a substantial matching between the perception of the 2 different point of view. The most cited, by older adults, activities conducted by 'homecare assistant are management of the house and preparing meals (91.6%), companionship (91.6%), personal hygiene support (91.6%)(Figure 18 Homecare assistant services reported by older adults). Comparing activities profile of the Homecare assistant described by older adults with the one described by the professions, we can appreciate that expect for the relevance of the user needs, there is a substantial correspondence between the two different point of view. The activities profile described by older adults receiving homecare services from rehabilitation staff include the following most cited activities needs assessment (100%), companionship (100%) and evaluation of the health conditions (83,3%).

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1.1 List of activities

Social guardian 18. educational interventions for your relatives and friends 17. positioning and supporting mobility 16. rehabilitation activities (walking, exercises, etc.) 15. pharmacological treatment and skin treatment 14. monitoring healthy lifestyle 13. Illness prevention interventions 12. Support to daily activities (shopping, going to a medical… 11. house management and cooking 10. personal hygiene (bathing, grooming, etc.) 9. education in health management and lifestyle 8. Assistance in the prescription and use of principals tools… 7. Home Environment assessment in terms of safety,… 6. support and assistance in social relationships 5. companionship 4. personal assistance planning 3.in-home health exams (e.g. taking blood sample) 2. evaluation of your health condition 1. evaluation of your needs

0

10

20

30

40

50

60

70

80

90 100

% older adults reporting activities

Figure 17 Social guardian services reported by older adults

Homecare assistant/home helper

1.1 List of activities

18. educational interventions for your relatives and friends 17. positioning and supporting mobility 16. rehabilitation activities (walking, exercises, etc.) 15. pharmacological treatment and skin treatment 14. monitoring healthy lifestyle 13. Illness prevention interventions 12. Support to daily activities (shopping, going to a medical… 11. house management and cooking 10. personal hygiene (bathing, grooming, etc.) 9. education in health management and lifestyle 8. Assistance in the prescription and use of principals tools you… 7. Home Environment assessment in terms of safety, hygiene,… 6. support and assistance in social relationships 5. companionship 4. personal assistance planning 3.in-home health exams (e.g. taking blood sample) 2. evaluation of your health condition 1. evaluation of your needs

0

10

20

30

40

50

60

70

80

90 100

% older adults reporting activities Figure 18 Homecare assistant services reported by older adults

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Rehabilitation staff 18. educational interventions for your relatives and friends 17. positioning and supporting mobility 16. rehabilitation activities (walking, exercises, etc.) 15. pharmacological treatment and skin treatment

1.1 List of activities

14. monitoring healthy lifestyle 13. Illness prevention interventions 12. Support to daily activities (shopping, going to a… 11. house management and cooking 10. personal hygiene (bathing, grooming, etc.) 9. education in health management and lifestyle 8. Assistance in the prescription and use of principals… 7. Home Environment assessment in terms of safety,… 6. support and assistance in social relationships 5. companionship 4. personal assistance planning 3.in-home health exams (e.g. taking blood sample) 2. evaluation of your health condition 1. evaluation of your needs

0

10 20 30 40 50 60 70 80 90 100

Figure 19 Rehabilitation staff services reported by older adults

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Answering to the question “What is the average time ACTUALLY spent by professional at your home each time he/she comes?” the older interviewed report different profile of time per performance based on the professional delivering the service. In particular (Figure 20 What is the average time ACTUALLY spent by professional at your home each time he/she comes?) the data show that the professionals the spend most time at home of the older adults, based on Modal Value, is the Homecare assistant/Home helper (from 4 to 8h), followed by rehabilitation staff and Social guardian (from 1 to 2 h). Comparing these data with the ones coming from the questionnaires administered to the HHCP, there is a substantial correspondence and matching between the older adults and HHCP point of view. 100,00 90,00 80,00 70,00

Social Guardian

60,00 Homecare assistant/home helper

50,00 40,00

Educator

30,00 Rehabilitation staff

20,00 10,00 0,00 > 15 minFrom 15 to 30 min From 1 to 2 hfrom 2 to 4 hfrom 4 to 8 h 24h/24h

Figure 20 What is the average time ACTUALLY spent by professional at your home each time he/she comes?

Analyzing the answers of older adults regarding the weekly frequencies of the services of HHCP Figure 21 How many times on average do you receive the visit of the professional at your home in a week?, the frequency of the service profile is variable for the different HHCP. In particular the modal value of the social guardian is from 2 to 3 times per week, the one of Homecare assistant form 5 to 7 times per week and Rehabilitation staff once or less than once per week. This data are partially coherent with the data coming from the questionnaire administered to HHCP. On the same questions the Social guardians interviewed reported that their performance frequency is from 2 to 3 times per week. The older adults reported that number of performances per week performed by Homecare assistant/Homecare helper are from 5 to 7 (mode value), in coherence with the description arising from the results of the HHCP questionnaire.

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120,00 100,00 Social guardian

80,00

Homecare asstistant/homehelper

60,00

Educator 40,00 Rehabilitation staff 20,00 0,00 1.Less than once

2. Once

3. From 2 to 4. From 3 to 5. From 5 to 6. More 3 times 5 times 7 times than 7 times

Figure 21 How many times on average do you receive the visit of the professional at your home in a week?

Answering to the question How can you define the relation/interaction that you normally establish with the professional that visit you at home? the older adults interviewed reported that the relationship perceived friendly (50,0% professional 46,4% deep 17.9% and distant 10.7%.Distinguishing between the different HHCP, the older adults perceive as friendly the social guardians, professional and friendly the rehabilitation staff and professional the Homecare assistant/home helper. 100,00 90,00 80,00 70,00 Social guardian

60,00

40,00

Homecare assistant/home helper Educator

30,00

Rehabilitation staff

50,00

20,00 10,00 0,00 1. deep

2. friendly 3.professional

4. distant

5. other

Figure 22 How can you define the relation/interaction that you normally establish with the professional that visit you at home?

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8.5 HHCP involved in older persons homecare service in Italy: roles and competences 8.5.1 Nurses In Italy there’s no specialization for nurses involved in homecare. After a three-year academic degree (EQF6), compliant with the “European agreement on the instruction and education of nurses”, Strasbourg, 25 October 1967 [Foreign and Commonwealth Office], nurses can provide public and private home nursing to older adults. The Bachelor’s Degree in Nursing, which belongs to the Nursing and Midwifery Class of degrees (Class SNT/1), is a three-year course divided into 6 terms (2 per academic year). Pursuant to Law no. 264 dated 2.8.1999 admission to any Nursing degree course involves a selective entry test. The course requires students to get 180 credits and aims at training health care professionals, equipping them with the scientific and technical knowledge and skills to work independently and provide assistance as nurses. Nursing assistance has a technical, relational and educational component and is provided to paediatric, adult and geriatric patients. Therapeutic, palliative and rehabilitation sides of the nursing practice are covered as well. The coursework meets the criteria and complies with the rules and regulations laid out by the European Union for the nursing profession. One of the most significant aspects of the training is the practical and clinical training, as laid out by the EU rules. The clinical training is carried out under the supervision of professional tutors and coordinated by fully-trained and highly respected clinicians. Students who hold a Bachelor’s Degree in Nursing can go on to study for Master’s Degree in Nursing and Midwifery.

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

Knowledge about: Hygiene-preventive sciences to understand health determinants, risk factors, individual and community prevention strategies, and interventions to promote the safety of health workers and patients.

Skills to: Promote health with preventive and healthcare interventions for patients, families, and the community; Initiate and support residual abilities of people to promote adjustment to limitations or alterations caused by disease and to modify lifestyles; - plan and implement, in collaboration

Competencies to: Use and apply theoretical models and role models within the healthcare process to improve, develop, recover, and promote the public’s health; Plan health educational campaigns in various social contexts and for different age groups.

HEALTH PREVENTION & EDUCATION

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SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

with other professionals information and educational activities to control risk factors for individuals or groups; - educate people to better health lifestyles and change hose at risk. NURSING

Knowledge about: - Biological phenomena, principal functioning mechanisms of organs and systems, hereditary and physiological phenomena, also in relation to the psychological, social, and environmental dimensions of health and illness.;

Skills to: - use the process of nursing care when taking charge of patients;

- fundamentals of physiology and pathology applicable to various environmental and clinical situations of a person;

- document nursing care that has been provided;

- the nursing care needs of individuals and the community and formulate the respective objectives; - the basic cultural and professional principals that guide the process, conceptuality, diagnostic reflection, nursing actions in relation to

- define intervention priorities based on healthcare needs, organizational needs and on the optimal use of available resources;

- identify the needs for nursing care, differentiated from the work done by support workers and other professionals; - handle computerized information systems and those using leaflets to support nursing care; - delegate and supervise caring

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Competencies to: - make nursing care decisions; - set nursing care intervention priorities; - decide which interventions to delegate to support workers; - conduct nursing care by customizing choices based on similitudes and differences among patients in relation to values, ethnic groups and socialcultural traditions; - critically assess the outcomes of nursing care decisions made in relation to patients’ responses and healthcare standards; - manage conflicts arising from diverging positions; 64 of 418

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know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

individuals and the community;

NURSING

activities to support workers; - collaborate with the healthcare team to agree the operational plans, and implement and develop protocols and guidelines.

- the general and clinical nursing sciences to understand the areas of nursing intervention, the clinical method that guides an effective approach to care, practical intervention techniques and scientific evidence that guide decision making.

- work within a team respecting everyone’s scope of practice;

Knowledge about:

Skills to:

Competencies to:

Ethical, legal and sociological sciences to understand the organizational complexity of the Health System, the importance and usefulness of abiding to rules and regulations, as well as the respect for values and ethical dilemmas that occur during daily practice;

Document nursing care provided according to legal and ethical principals;

Plan and implement appropriate nursing interventions that consider people’s values and beliefs;

Ensuring that patients and their families and/or significant others get the information and support for healthcare continuum and the recovery of one’s health resources.

Being responsible for actions linked to their roles and being accountable for actions related to their profile (DM 739/94), the code of conduct, and ethical and legal standards.

Professional autonomy, areas of integration and interdependency with other members of the healthcare team;

Ensure and effective physical and psychosocial environment for the safety of patients;

Establish and maintain helpful relationships with their patients and their families, by applying the fundamentals of relational dynamics.

Basic and applied biomedical sciences

Adopt actions that protect from

- check patients’ problems with structured and systemic techniques by detecting alterations in the functional models.

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to understand the physiological and pathological processes linked to the health and illness of people across their life span.

physical, chemical, and biological risks in the workplace;

Public health-preventive sciences to understand health determinants, risk factors, prevention strategies, both individual and collective, and interventions aimed at promoting the safety of health workers and patients.

Identify and manage risk factors. Ensure safety and risk control during patient care.

Take precautions when manually moving weights; Adopt strategies for the prevention of infectious risks (standard precautions) both in hospitals and in the community; Use validated clinical healthcare instruments to manage clinical risk (e.g. pre-op check-lists, fall charts)

THERAPEUTIC EDUCATION

Knowledge about: Psycho-social and humanistic sciences to understand the normal and pathological relational dynamics, and people’s defence reactions and adjustment to situations of psychic, social distress, and physical suffering; Learning and change theories to understand educational processes for

Adopt risk management tools to manage adverse events Skills to: Design with patients and their families educational projects to develop selfcare skills;

Competencies to:

Adopt communication models that facilitate the understanding of the educational project;

Use appropriate communications skills (verbal, non-verbal, and written) with patients of all ages and with their families within the healthcare process and/or with other health professionals in the appropriate verbal, non-verbal and written form;

Set up informal healthcare networks

Use teaching and learning principals

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to support patients and their families during long term healthcare projects;

for specific information and educational interventions for individuals, families, groups, and other professionals (support workers, nurse students, nurses);

the public and patients; Group dynamics and managing groups

Plan patient discharge.

Support and encourage people to make healthcare choices, reinforcing coping skills, self-esteem and enhancing available resources. RESEARCH

Knowledge about:

Skills to:

Competencies to:

Computer and languages disciplines, particularly English in order to understand nursing scientific literature and use databases;

Search the literature according to the issues that emerge from clinical practice;

Apply nursing research results to improve the quality of care;

Critique the literature;

Use instruments and methodologies to evaluate and review the quality of care;

Conduct evidence based practice based on patients’ values, beliefs and preferences, available resources and clinical judgement.

Provide safe, effective, and evidence based nursing care.

Knowledge about:

Skills to:

Competencies to:

- General and clinical nursing sciences, and national and international

Apply, manage and document diagnostic and therapeutic pathways;

Use appropriate communication methods within the multiprofessional

The methodological approach to quantitative and qualitative research, Evidence Based Nursing and Best Practice

MANAGEMENT

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regulations to manage and organize care in order to facilitate the fields of nursing intervention and improve patient and family outcomes.

- Ensure correct application of therapeutic protocols and monitor their efficacy;

team;

- The clinical method as an effective approach to care, and operational intervention techniques that guide decision-making;

- Start decision making processes based on the patient’s conditions, altered vital signs, medical reports and lab tests;

- Psycho-social and humanistic sciences to understand the relational dynamics within a working group.

- Manage diagnostic pathways ensuring an adequate preparation of the patient and surveillance after the procedure; - Integrate nursing care in the multidisciplinary care plan; - Use instruments for professional integration (meetings, team meetings, case discussions); - Start interventions required to manage acute and/or critical situations;

- Manage conflicts caused by diverging positions; - Facilitate the coordination of care to achieve the agreed healthcare outcomes; - Be accountable of one’s work during practice in line with the professional profile, the code of conduct and ethical and legal standards; - Make decisions using a scientific approach to solve patients’ problems; - Analyse organizational problems and suggest solutions; - Make decisions when there are diverging positions (conflicts or dilemmas).

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patients. EDUCATION

Knowledge about:

Skills to:

Competencies to:

The educational approaches described in the andragogical model; - Regulations about gaining continued medical education credits.

Check one’s own learning needs;

To supervise students during their clinical learning placements, educate and facilitate the introduction of newly employed nursing staff, train support workers, and refresh one’s own level of education and competencies;

- Design learning plans to run educational activities that support professionalization; - Take leading roles over support workers and/or students; - Develop one’s own profile; - Collaborate in the design, provision, and assessment of educational programmes.

8.5.2 Physiotherapists The physiotherapist is an health care professions of rehabilitation (L/SNT2) which requires a 3 years degree (180 credits) Physiotherapy graduates are healthcare professionals who carry out, independently or working with other professionals, prevention, treatment and rehabilitation work for motor skills, higher brain function and visceral function, after a pathological event has occurred. 562634-EPP-1-2015-IT-EPPKA2-SSA

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Physiotherapy graduates draw up, on their own or with a team, on the basis of a doctor’s diagnosis and prescription, a rehabilitation plan aimed at identifying and meeting the health needs of a disabled person; independently carry out treatment for the functional rehabilitation of motor, psychomotor and cognitive functions (physical therapy, manipulation, massage and occupational therapy); recommend the use of prosthetics , orthotics and other devices and help patients get familiar with them and make sure they are effective; they make sure that their rehabilitation techniques meet the goals of functional recovery; they offer consulting and training for health care services and wherever they are needed.

ROLE3 (SET OF ACTIVITIES) PREVENTION

CARE AND REHABILITATION

3

KNOWLEDGE know what - theoretical and/or factual knowledge

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Knowledge of health needs and the modalities for preventing disabilities

Know how to promote health needs and the modalities for preventing disabilities

Evaluate how and when to promote health needs and the modalities for preventing disabilities

To promote actions for health promotion and for overcoming disabilities

Know how to act for health promotion and for overcoming disabilities

Evaluate how and when implement actions for health promotion and for overcoming disabilities

Knowledge of methods for preventing increased of disabilities

Know how to implement actions for preventing increased of disabilities

Evaluate how and when implement actions for preventing increased of disabilities

Knowledge of individual and community needs related to physical, philological and social fields/environments subjected to functional recovery

Know how to identify individual and community needs related to physical, philological and social fields/environments subjected to functional recovery

Evaluate how and when act on individual and community needs related to physical, philological and social fields/environments subjected to functional recovery

Source: AIFI – Italian Physiotherapists Association - Physiotherapist Core Competencies http://aifi.net/wp-content/uploads/2013/01/corecompetencecorecurriculum.pdf

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Knowledge of the acquisition and explanation modalities regarding data from physiological and pathological anamnesis, body parts and its physiology as well as activities related to individual and environmental factors

Know how to collect and read data from physiological and pathological anamnesis, body parts and its physiology as well as activities related to individual and environmental factors

Knowledge of different processes related to patients’ evaluation consisting of reliable clinical and instrumental tests and clinical examination

Know how to carry out patients’ evaluation by means of reliable clinical and instrumental tests and clinical examination

Knowledge of analysis and evaluation processes in order to: (i) determine functional abilities and potential outcomes related to clients and caregivers choices and (ii) to express a functional diagnosis and based on that the prognosis

Know how to evaluate and analyse clinical and instrumental data in order to (i) determine functional abilities and potential outcomes related to clients and caregivers choices and (ii) to express a functional diagnosis and based on that the prognosis

Knowledge of the processes for determine the therapeutic goals, intervention priorities, the ongoing

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Evaluate a clinical reasoning based on clinical and instrumental information in order to(i) determine functional abilities and potential outcomes related to clients and caregivers choices and (ii) to express a functional diagnosis and based on that the prognosis Be able to define and determine the therapeutic goals, intervention priorities, the ongoing evaluations

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TRAINING AND SELF-LEARNING

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evaluations based also on client/caregivers choices.

based also on client/caregivers choices.

Knowledge of different evaluation modalities (also as working as a team), and of the rehabilitative intervention efficacy.

Be able to carry out clinical and instrumental evaluation (also in a context of team working), and be aware of the rehabilitative intervention efficacy.

Knowledge of the basis for building educational programs for clients and care-givers and verifying its pertinence.

Know how to identify the basis for building educational programs for clients and care-givers and verifying its pertinence.

Knowledge of teaching and educational activities for supporting individual and community well-being by means specific interventions

now how to carry out teaching and educational activities for supporting individual and community well-being by means specific interventions

Knowledge of processes for adapting teaching courses based on learning and training needs and competences and verifying their pertinence.

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dealing with standard and specific situations requesting comparison and feedback about your intervention to training tutors and self assessing the implementation of knowledges and skills EBP – EVIDENCE BASED PRACTICE

PROFESSIONAL RESPONSIBILITY

COMPETENCIES know how to be dealing with standard and specific situations requesting comparison and feedback about your intervention to training tutors and self assessing the implementation of knowledges and skills

Knowledge of how to put a question starting from a specific clinical issue, putting it in order to come to a simple answer and how to design the most appropriate way to answer.

Know how to find available clinical evidences by consulting proper general and specific databases and main search engines; Know how approach critically the scientific production

Be able to assess the opportunity to modify your clinical practice on the base of collected evidences acknowledging the patient's needs and your experience (about EBP and EBH)

Knowledge of scientific literature sources, of different kind of studies and their hierarchy

Know how to identify, basing on a question, the most appropriate research project to properly answer.

Be able to consult clinical research in order to modify your clinical practice

Know how to find, read and analyse critically the current scientific literature by consulting proper databases both general and specific and main engine searches.

Be able to modify your clinical practice acknowledging patient's values\needs and your experience.

Knowledge of the evolution of the profession and discipline, knowledge of the concepts of autonomy and

Know how to take charge of the Be able to practice in observance of person in respect of professional professional profile, deontology and ethics and deontology; know how to

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accountability regarding the PT;

protect the profession;

law regarding the profession.

Knowledge of the relation between the PT and other professionals; in depth analysis about ethics, deontology and legal alt both national and European level.

Ensure an appropriate intervention respecting professional boundaries and your level of experience.

Knowledge of cultural and society related different needs

Know How to receive patients and relatives in different context; Know how to show respect and sensitivity for the patient, for his right, for his dignity and personal aspects, including age, sex, lifestyle, ethnic group, language, health condition, behavioural and cognitive

Be able to behave in respect of different ethnic implications regarding his corporeity different ways of communicate with the patient considering feelings, thoughts, cultural and religious principles

knowledge of patient's and caregiver's cantered approach

Know How to involve patients and caregivers in making decisions process

Be able to involve and inform patients and relatives about the chosen intervention (Prevention, care and rehabilitation) in order they can accept or refuse the therapeutic proposal.

Knowledge of the legal aspects concerning the profession about accountability, information, listening

To know how to act in respect of Be able to collect agreement where needed, know how to behave in patient's privacy and confidentiality

Keep a polite relation between PT and other involved subjects.

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and agreement in healthcare area; about privacy, personal and sensitive data, patient's confidentiality

MANAGEMENT

COMPETENCIES know how to be observance of patient's confidentiality

Knowledge of the accountability of your own decisions and actions

Know How to support your own Be able to ensure efficient and effective performance for the best professional choices patient's interest implementing criteria of transparency of the price list

Knowledge of the main theories about interpretation and knowledge of making decisions process

Know how to utilize the phases of the process in the clinical area; Know how to find adaptive solutions to overcoming problems

Be able to implement problem-solving in making decisions

Knowledge of your working institution

Know how to manage your duty into your institution

Be able to operate acknowledging roles and competencies of other equip members, know how to unify operative modalities; know how to underline problems and to propose solutions; know how to monitor outcomes

Knowledge of clinical risk and operating by quality standards

Know how to identify adverse events; know how to manage clinical risk

Be able to operate safely by him/herself and others, know how to implement strategies to minimize risk possibility

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COMUNICATION AND RELATIONS

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COMPETENCIES know how to be

Knowledge of delivering quality standards

Know how to deliver quality standards by using operational and computerized tools to collect and analyse data; Know how to analyse critically the process in order to solve issues.

Be able to manage the work by managing spaces, time, assets and working plans using data collection to apply corrections if needed.

Knowledge of establishing and supporting an effective way of communication with the patient and other related professional

Know how to write effectively to patients, caregiver and others related professionals

Evaluate how and when to establish and manage an helping relationship with patients and care-givers

Knowledge of communicating effectively with other healthcare professionals or other significant professionals to ensure an effective and efficient service to the user

Know how to cooperate with other members of the team about the planning, supervision and assessment of the patient’s outcomes

Evaluate how to manage the relational issues between the team\working group

Knowledge of managing objectives and solve clashes

Know how to manage objectives and solve potential clashes

Be able to implement strategies to prevent\solve clashes

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8.5.3 Psychologist Despite the indication of the Ministry of health, in Italy are very few the psychologist working in public services in homecare sector for older adults. Clinical psychological intervention are most performed in private sectior and in studio setting. There are no specific training course and competences definition for older adults homecare. There are several post degree courses on psychogeronthology and aging psychology, but these are not mandatory to perform work as psychologist in homecare for older adults. The profession of psychologist, as described by the Law of. 18 Febrary 1989, n. 56., includes the use of knowledge and tools for the intervention to prevent, diagnose and rehabilitate and support in psychological field for people, groups, social institutions and communities. Includes the activities related to experiment, research and education in this field. As described in the art.2 of Law of. 18 February 1989, n. 56.,the requirements to practice the psychologist profession is necessary • •

to have obtained the master degree in psychologist, to be in possession of proper documentation proving the execution of a training period accordance with rules laid by the Minister of Education to have obtained the qualification thought the state certification exam to be a member of the professional board.

• •

There are no detailed documents describing role, activities, competences for the psychologist working in the homecare for older adults. In the list of the more frequent activities performed by professionals in the home care ( Nuova caratterizzazione dell’assistenza dell’assistenza territoriale domiciliare e degli interventi ospedalieri a domicilio, 2006), the ones related to psychological roles/activities includes: 1. 2. 3. 4.

Supportive care for patients and families Individual consultation to operators of the team Supervision of team activities Support talks and elaboration of mourning

Despite these list provided by Ministry of Health regarding the most frequent activities performed by psychologists, there are other activities not included in the list, that could be requested by a psychologist in the homecare for older adults setting. The main occupation of psychologist in the clinical field are defined by “La Professione Di Psicologo: Declaratoria, Elementi Caratterizzanti Ed Atti Tipici” (National Order of Psychologists, 2015) and the competences can be extracted from the definitions of the Master degree in Psychology (LM – 51) and the definition of the knowledge, skills and competences defined by “Determinazione delle classi di laurea magistrale” (Decreto Ministeriale 16 marzo 2007 Pubblicato nella Gazzetta Ufficiale del 9 luglio 2007 n. 155) and “Riassetto delle Scuole di Specializzazione di area Psicologica” (Decreto Ministeriale 24 luglio 2006 Pubblicato nella Gazzetta Ufficiale del 21 ottobre 2006 n. 246).

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capacity of independent and critical judgment in evaluating individual situations, family, community and organizational.

PREVENTION

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He knows the main explanatory theories in the field of general and physiological psychology, social psychology and community, dynamic and clinical psychology; psychopharmacology; psychogeriatrics; psychiatry; neurology

work with appropriate methodologies for the promotion of health and wellbeing

has knowledge in related disciplines and complementary to the psychological sciences, specifically in the field of neuroscience and the philosophical disciplines, anthropological,

use the knowledge and methods acquired to work in multidisciplinary teams, offering in this area a specific

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is able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / behaviors on the basis of the monitoring results capacity of independent and critical judgment in evaluating individual situations, family, community and organizational.

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sociological and pedagogical

psychological support;

He knows the main explanatory theories in the field of general and physiological psychology, social psychology and community, dynamic and clinical psychology; psychopharmacology; psychogeriatrics; psychiatry; neurology

- applying diagnostic tools;

be able to learn from the experience and collaboration with colleagues and also professionals from other disciplines. be able to interact with different professional psychologist; capacity of independent and critical judgment in evaluating individual situations, family, community and organizational. be able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / behaviors on the basis of the monitoring results;

DIAGNOSIS

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has knowledge in related disciplines and complementary to the psychological sciences, specifically in the field of neuroscience and the philosophical disciplines, anthropological, sociological and pedagogical

ABILITATION/REHABILITATION

He knows the main explanatory theories in the field of general and physiological psychology, social psychology and community, dynamic and clinical psychology; psychopharmacology; psychogeriatrics; psychiatry; neurology

use the knowledge and methods acquired to work in multidisciplinary teams, offering in this area a specific psychological support;

Apply with responsibility the mastered knowledge about design, development and evaluation of interventions targeting individuals, groups and communities in different contexts

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capacity of independent and critical judgment in evaluating individual situations, family, community and organizational. be able to learn from the experience and collaboration with colleagues and also professionals from other disciplines. be able to interact with different professional psychologist; capacity of independent and critical judgment in evaluating individual situations, family, community and organizational. is able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / 80 of 418

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behaviors on the basis of the monitoring results;

He knows the methods of design and evaluation of interventions in individual field, group, community and organizational;

has knowledge in related disciplines and complementary to the psychological sciences, specifically in the field of neuroscience and the philosophical disciplines, anthropological, sociological and pedagogical

use the knowledge and methods acquired to work in multidisciplinary teams, offering in this area a specific psychological support;

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They will also be able to manage the complexity arising from the analysis this situation and making decisions about the choice of interventions aimed at individuals, groups or communities. able to communicate effectively with colleagues of other disciplines, offering precisely specific contribution; be able to learn from the experience and collaboration with colleagues and also professionals from other disciplines. be able to interact with different professional psychologist; capacity of independent and critical judgment in evaluating individual situations, family, community and organizational.

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He knows the main explanatory theories in the field of general and physiological psychology, social psychology and community, dynamic and clinical psychology; psychopharmacology; psychogeriatrics; psychiatry; neurology SUPPORT

applied maturely and responsibly the knowledge gained in the design, implementation and evaluation of interventions aimed at individuals, groups, communities, in different organizational contexts;

He knows the methods of design and evaluation of interventions in individual field, group, community and organizational; has knowledge in related disciplines and complementary to the psychological sciences, specifically in the field of neuroscience and the philosophical disciplines, anthropological,

use the knowledge and methods acquired to work in multidisciplinary teams, offering in this area a specific

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Be able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / behaviors on the basis of the monitoring results; be able to manage the complexity arising from the analysis this situation and making decisions about the choice of interventions aimed at individuals, groups or communities. Be able to communicate effectively with colleagues of other disciplines, offering precisely specific contribution; be able to learn from the experience and collaboration with colleagues and also professionals from other 82 of 418

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sociological and pedagogical

psychological support;

PSYCHOTHERAPY

He knows the main explanatory theories in the field of general and physiological psychology, social psychology and community, dynamic and clinical psychology; psychopharmacology; psychogeriatrics; psychiatry; neurology

applied maturely and responsibly the knowledge gained in the design, implementation and evaluation of interventions aimed at individuals, groups, communities,

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disciplines.

Be able to interact with different professional psychologist; be able to manage the complexity arising from the analysis this situation and making decisions about the choice of interventions aimed at individuals, groups or communities. be able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / behaviors on the basis of the monitoring results;

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General theoretical knowledge of the fundamental pathogenetic mechanisms of central nervous system diseases, peripheral and vegetative, psychiatric disorders, personality disorders and specific forms of psychological distress of the different phases of the life cycle; general theoretical knowledge and basic experience related to neurological diseases, psychiatric, neuro- and psychomotor, also with reference to behavioral and psychological complications of internal medical and metabolic diseases and organ diseases throughout the life cycle and with particular reference to their psychological impact on family and social contexts the methods of design and evaluation of interventions in individual field, group, community and organizational; has knowledge in related disciplines and complementary to the psychological sciences, specifically in the field of neuroscience and the philosophical disciplines, anthropological, sociological and pedagogical

be able to develop evaluation capacity about problems and situations through the use of knowledge and information acquired formulating judgment of priorities and the reasons for it, anticipating outcomes of their choices with possible consequences / effects and developing strategies to redefine the objectives / behaviors on the basis of the monitoring results; able to communicate effectively with colleagues of other disciplines, offering precisely specific contribution;

use the knowledge and methods acquired to work in multidisciplinary teams, offering in this area a specific psychological support;

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be able to learn from the experience and collaboration with colleagues and also professionals from other disciplines.

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It is able to interact with different professional psychologist; be able to communicate effectively with stakeholders within organizations;

MANAGEMENT

Knowing the territorial social health organization (ex ASL, MMg ..), regional, national and european

Knowing how to define its own role, to his affiliation or professional free scheme to delineate the frames and potential of the work Knowing how to Report the own work, handle tools properly and securely.

be able to communicate effectively with stakeholders within organizations; It is able to interact with different professional psychologist;

the voluntary sector and voluntary work

8.5.4 Professional Educator A graduate of the Professional Education (Health Care Profession) degree. Professional Educators are health care professionals specialised in rehabilitation. Their work activities contribute to specific projects in the fields of education and rehabilitation to promote a balanced development, rehabilitation and social reintegration of physically or psychologically disadvantaged individuals, or people who are at risk of being socially marginalised.

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COMPETENCIES know how to be -

SKILLS know how to do - SKILLS as cognitive and practical Start a relationship

Know how to relate to the individual, their family, the community

Create new relationships

RELATIONSHIP

Be familiar with social participation and active citizenship processes

ELEMENTS OF GERIATRICS

Maintain, strengthen, and repair existing relationships

Learn about the process of ageing (physical, cognitive, psychological and social issues)

Encourage social life by making the most of the community’s resources

Use an ‘educational relationship’in order to establish rapport with the individual and their family, ascertain the person’s needs, share the proposed plan with them, keep on sustaining the relationships that make it possible for the necessary support to the educational process to be found within the family and the community. Encourage participation in activities and events organised by external agencies and services

Slow down physical decline (encouraging physical exercise in cooperating with physiokinetic therapy)

Together with the working team to identify actions to be taken in order to promote active ageing, i.e. adopting a new lifestyle that can slow down or counter the loss of functions/abilities

Slow down cognitive decline (formal and informal ROT, promoting space and time orientation and adapting your

Promote strategies to maintain the main cognitive functions (focus, memory, language)

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Promote psychological welfare Preventing social decline (encouraging people to engage ‘actively’ in the community – free time activities and volunteering )

HANDLING AUTONOMY

Be familiar with ADL And IADL (instrumental activities of daily living)

Assess the ability to make a meal, maintain personal hygiene, get dressed, deal with domestic chores, take meds, be out and about, take public transport, use a phone, … Monitor the environment

HOME ECONOMICS

Be familiar with the basics of looking after the home

Systematic observation Put into place strategies to challenge and help the person to carry out daily life tasks in order to promote autonomy and independency Identify risks in the home

Promote a prosthetic environment

Adapt the environment, especially for dementia/cognitive deficit cases

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ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

Be familiar with the basic of healthy eating

Prevent risk for mental and physical health

THERAPEUTIC ALLIANCE

Monitor the person’s health

Be familiar with the basics of keeping safe while moving (assess the risk of falls)

Therapy intake

Team work

Be familiar with the network of services (health and social professional, social and health organisations – administrative offices, clinics, day centres, residential facilities…)

COMPETENCIES know how to be -

SKILLS know how to do - SKILLS as cognitive and practical Help the elderly person eat healthily Report a health risk (to whom, how, timeframe) To the family, the team members, the local services Take actions to reduce risk with individual educational activities Check the person health condition from time to time by enabling his access to the MMG and other medical units in his area Implement strategies to have the elderly person appropriately escorted when he/she leaves the house Help the person when it comes to handling the medicines he/she has to take and check that he/she takes them correctly. Point the elderly or their relatives to the main existing services that can improve their quality of life and help the family.

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Help the elderly person to do/manage their shopping Assess domestic risk to physical and mental health, using the rapport with the person and the family which is based on trust and cooperation

Work with the GP and familiarity with local services Identify tools that can be of help when the person is out and about (cane, walking frame, etc.) with the help of the doctor/physical therapist Action that requires working closely with a GP and a RN

Be familiar with and able to assess the procedure to get a service to take on the elderly person

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ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

COMPETENCIES know how to be -

SKILLS know how to do - SKILLS as cognitive and practical

Promote active citizenship

Get formal and informal support going to promote an active lifestyle

Get a support network going (friends, volunteers, acquaintances)

Regularly meet as a team to write down the IAP and assessment

Design long and medium term educational actions

Work with social and health professionals in a shared design perspective

8.5.5 Occupational Therapist Occupational therapists are identified by Italian law as one of the health professions for rehabilitation. After a three-year academic degree (EQF6), they can provide public and private homecare to older adults. During the primary prevention stage, the Occupational Therapist fosters a healthy lifestyle at different levels: for the individual, the group, the organization and the community. During the secondary prevention stage the Occupational Therapist focuses on the individuals, with or without disabilities, who found themselves at risk of performance problems in order to prevent negative factors to arise or increase, as they may affect the performance. During the third prevention stage the Therapist fosters occupational performance at all ages and in any kind of physical and mental dysfunction, be it either temporary or permanent. ROLE4 (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical

4

Source: AITO – Italian Occupational Therapists Association - Occupational Therapist Core Competencies http://www.aito.it/sites/default/files/Competenze%20Generali,%20Specifiche%20e%20Professionali.pdf

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KNOWLEDGE know what - theoretical and/or factual knowledge

OCCUPATIONAL THERAPY Basic notions of biologic, medical, human, PROCESS AND A psychological, social, technologic sciences PROFESSIONAL WAY OF in professional way of thinking THINKING Be familiar with the critical issues of implementing formal theories and scientific evidence to the field of employment, in the context of an everchanging society

Be familiar with employment nature of human beings and their employment performance Be familiar with the relationship between occupational performance, health and wellness

PROFESSIONAL INDEPENDENCE AND RESPONSIBILITY

Be familiar with the main documents of the occupational therapy process

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical Implement relevant knowledge from biological, medical, human, psychological, social and technologic sciences in a professional way of thinking Identify patient employment profile

Make use of the therapeutic value of employment

Explain the relationship between occupational performance, health and wellness Lay down a therapeutic relationship as the basis for the therapeutic occupational process

Analyse the types of employment Adapt and implement occupational therapy processes in close collaboration with users

Set up collaborative relationships, get opinions from clients, family, members of the team and management in order to make employment and active participation easier

Prepare, manage and update documents about the occupational therapy process

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KNOWLEDGE know what - theoretical and/or factual knowledge Be familiar with local, regional, national and European protocols and procedures; professional standards and employer rules Be familiar with the role of occupational therapist in relation with the other professionals who work alongside occupational therapists Be familiar with the main concepts of information technology and Internet Be familiar with the main clinical evidence sources

MANAGEMENT OF SOCIO-WELFAREREHABILITATION NEEDS OF THE PEOPLE IN THE PRIMARY PREVENTION STAGE BOTH SANITARY AND SOCIAL

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical Carry out client-centred work

Practice the profession ethically, respecting clients and professional standards and ethics Know how to work in a team

Know how to surf the net, carry out researches, use email systems and main information technology systems Know how to carry out an internet search and using the main clinical evidence databases

Be familiar with occupational theories in relation with lifestyle and occupational roles

Understand, analyze, summarize and review critically the results Assess individual/ group/organization/community lifestyle and occupational role in order to identify possible factors limiting occupational success Evaluate the socio-sanitary context in order to identify the pros and cons in terms of individual/ group/organization/community occupational wellness

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KNOWLEDGE know what - theoretical and/or factual knowledge Be familiar with the theories and professional practice models in order to satisfy individual / group/ organization / community needs

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical Implement theories and professional practice models in order to satisfy individual / group/ organization/ community needs

Be familiar with theories and rules in order to evaluate the accessibility and safety of the places we live in (external spaces included), as well as routes Be familiar with the main characteristics of daily life places (home, school, community/territory) should have

MANAGEMENT OF SOCIO-WELFARE NEEDS OF PEOPLE IN THE SECONDARY PREVENTION STAGE BOTH SANITARY AND

Evaluate accessibility and safety of the places we live in (external spaces included) as well as routes

Be familiar with the main theories and rules of the design of workstations and the furnishing of accessible and ergonomic settings Be familiar with the standard instruments for preliminary identification of negative factors for occupational performance

Design workstations and furnish rooms in order to ensure accessibility and ergonomics

Be familiar with the main risk factors

Reduce risk factors through occupational involvement

Evaluate daily life places in order to check if they satisfy individual/group/community occupational needs Be able to provide consultations on workstation design and accessible and ergonomic furniture

Use standard instruments for preliminary identification of negative factors for occupational performance

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SOCIAL

Management of sociowelfare needs of people in the THIRD PREVENTION stage both sanitary and social

KNOWLEDGE know what - theoretical and/or factual knowledge

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical

Be familiar with occupational perspectives in order to prevent disease and disabilities and to foster health

Provide consulting to and collaborate with organizations and communities on how those occupational perspectives are able to prevent disease and disabilities and promote health Operate in order to keep independence in everyday activities, in social interactions and mobility within the community of the individual/the group/ the organizations/ the communities which are at risk of compromised occupational performance

Foster the setting up of a “social network” in order to ease the integration of the individual in his/her daily life, in collaboration with local resources

Be familiar with the main preparatory devices for occupational performance recovery

Be familiar with the main preparatory devices for occupational performance recovery

Evaluate and foster the use of the main preparatory devices for occupational performance recovery

Be familiar with theories and procedures in order to draw up an employment profile of the patient in acute phase or post-acute phase

Draw up an employment profile of the patient in acute phase or post-acute phase

Evaluate performance skills in personal care

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Evaluate body structures and functions in relation with occupational performance Evaluate lifestyle before the acute phase occurrence

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KNOWLEDGE know what - theoretical and/or factual knowledge Be familiar with the main characteristics of the projects about: recovery (development and restore); change (compensation and adaptation); prevention; promotion or keeping in order to reinsert the user in the job setting

COMPETENCIES know how to be

SKILLS know how to do - SKILLS as cognitive and practical Analyse, adapt and phase in employment through the analysis of occupation. Plan an employment action in order to foster health and wellness

Evaluate limits in activity

Ensure continuity in welfare-rehabilitation activities in the user’s life and set the focus on the integration of local structural and professional resources

Collaborate with a multi professional team in order to focus the therapy on the early promotion of independence

8.5.6 Social Health Operator (OSS) This new figure, known as OSS – Social-Health Operator (operatore socio-sanitario), was introduced by The State-Regions Conference of 22nd February 2001. It should replace a number of figures that has been historically involved in home nursing: ASA - Social-Assistance Auxiliary (ausiliario socio assistenziale), OTA Assistance Technical Operator (operatore tecnico addetto all'assistenza), OSA Social Assistance Operator (operatore socio-assitenziale)and ADEST Homecare and Tutelary Services Assistant ( Assistente domiciliare e dei servizi tutelari) are some examples of figures who have been trained and employed in the homecare sector in the last years.

After that conference, each region was meant to ratify this recommendation in local laws, specifying how to manage the necessary integrative training for people who already got ASA, OTA, OSA and ADEST qualifications in order to convert them into OSS qualification. This issue has been managed at local level in different ways, so at national level there’s no uniformity about the training paths followed by these professionals. A social-health operator is a qualified professional whose job description centres on meeting the main needs of a patient, in a social or health care setting, by promoting the patient’s autonomy and welfare. A social-health operator’s main tasks focus on the assisted and his/her environment. They include:

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a) direct assistance and domestic help; b) hygiene/health-related help and social support; c) educational and management support. Social-health operators work within the framework of social services or healthcare services (in residential, or semi-residential facilities, in hospitals or in the users’ own houses). Regions are in charge of providing the training for social-health operators, in accordance with the existing rules and regulations. The regional and independent provincial authorities accredit local healthcare agencies, hospitals and public or private organisations (provided that these meet the requirements laid down by the Ministry of Heath and the Department of Social Affairs) to carry put the training courses.

ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

Basic knowledge of home ENVIRONMENTAL environment safety MONITORING Basic knowledge of hygiene: personal hygiene, home environment hygiene, health care operator’s hygiene

HEALTH MONITORING

SKILLS know how to do - SKILLS as cognitive Being able of identifying home environmental health risks

COMPETENCIES know how to be Implementing safety procedures in home environments Implementing environmental sanitisation procedures

Being able of guaranteeing home environment hygiene and safety conditions and care (home cleaning, food, etc.)

Performing activities aimed at assuring personal hygiene, fulfilment of physiological functions, proper use of health aids and devices, proper positioning and postural behaviour

Knowledge of the general provisions applying to workers’ health Being able of acting in order to protection and safety reduce risk levels

Adopting specific procedures to ensure elderly patients’ safety by reducing risks at a minimum

Knowledge of elements of anatomy Being able of applying the various and physiology steps for customised interventions

Implementing procedures to monitor non self-sufficient elderly’s psychophysical health

Knowledge of elements of pathology

Adopting communication strategies with elderly patients

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Implementing medical and health procedures

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ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge Knowledge of the main indicators of risk conditions related to psychophysical pathologies

SKILLS know how to do - SKILLS as cognitive Being able of detecting risk conditions and the most common syndromes of bedridden and immobilised elderly patients Being able of supplying basic elements of health education to elderly patients and their relatives

EQUIPE WORK

Knowledge of social and health care procedures

Being able of interacting with social and health service organisations and informal health networks

COMPETENCIES know how to be Implementing procedures to ensure the proper assumption of the prescribed medicines Implementing supporting procedures to assist with the mobilization, ambulation and transport of non self-sufficient elderly patients Implementing checking procedures for socio-sanitary interventions Implementing teamworking strategies Involving informal networks, and establishing relationships with local social and cultural facilities and recreational centres Adopting common working procedures, records, protocols, and implementing schemes to detect non self-sufficient patients’ psychophysical requirements in collaboration with other professional figures

ADMINISTRATIVE SUPPORT

DAILY LIFE ACTIVITIES

Knowledge of elements of labour law Being able of understanding and employment status management, organisation and training strategies Knowledge of elements of health legislation and health services Being able of using information organisation technology tools to record health care-related data Knowledge of psychological and Being able of adopting the proper relational dynamics and health care social and health care strategies procedures to meet elderly patients’ with elderly patients with different 562634-EPP-1-2015-IT-EPPKA2-SSA

Using information technology tools to record data related to health care treatments

Implementing procedures to support elderly’s social integration

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ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge specific needs

SKILLS know how to do - SKILLS as cognitive degrees of psychophysical loss of autonomy

COMPETENCIES know how to be Staging entertainment activities for elderly patients

Knowledge of elements of ethics and Implementing technical procedures to help non self-sufficient deontology Being able of establishing the proper patients get dressed and take care of their clothing interpersonal relationships with Knowledge of elements of household suffering, disoriented and distressed Supporting non self-sufficient patients with food intake administration elderly patients Establishing good relations with elderly patients and their Knowledge of socialising patterns Being able of providing home or families by actively interacting in all daily care activities residential care to elderly patients with different degrees of Performing professional activities ethically and discreetly psychophysical loss of autonomy Being able of promoting socialisation activities

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8.5.7 Homecare assistant / home helper The Homecare Assistant is the main figure who provides social homecare / home aid to older adults. This figure is not included in the legislation of all regions (sometimes it is called Home Assistant or Family Help and its profile varies slightly). Despite this, this role has become more and more significant, especially because there is an ever growing number of social co-operatives which provide assistance to minors, the elderly and the disabled on behalf of councils. The employment relationship for this figure is laid out in CONTRATTO DI LAVORO DOMESTICO C.C.N.L. (Domestic Labour Contract – Collective bargaining agreement) which is valid from 01/07/2013 to 31/12/2016 Every region has its own official registry for family assistants, the requirements for which vary from region to region, especially in terms of training, ranging from a minimum of 32 hours to a maximum of 300 hours. Some regions requires assistants to provide proof of one-year experience. The training courses cover different amounts of content due to the different course length. In general, they all cover topics such as domestic chores and domestic hygiene, personal hygiene, meal preparation, environmental safety, coordinating social and health services. A person can apply to be included in the official registry if he/she: is over 18; has completed compuslory education has never been convicted of a crime which relates to professional standards, pursuant to art. 44 of the criminal code ; is medically fit; has undergone the relevant training or can provide he/she has already worked as an assistant for at least one year Non-EU citizens need to provide a valid residence permit for paid employment and prove they have an adequate mastery of Italian. ROLE5

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

know how to be

Psychophysical characteristics of people with different levels of self-sufficiency PATIENT CARE AND SUPPORT

Basics of food education and dietary therapy

Implement food preparation techniques

Basics of food hygiene Basics of sanitary education

5

Regione Liguria Professional Repository – Homecare Assistant Competencies http://professioniweb.regione.liguria.it/Dettaglio.aspx?code=0000000117

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KNOWLEDGE

SKILLS

COMPETENCIES

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know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

know how to be

Basics of socio-educational assistance, with reference to private standard services Basics of Ethics in personal services Basics of residual abilities management

Implement non-self-sufficient user psychophysical need survey techniques Implement support techniques for non-selfsufficient user in keeping residual abilities and in functional rehabilitation Implement support techniques for non-self sufficient users’ personal hygiene

Basics of personal hygiene

Implement active and shared communication techniques with non-self sufficient user Implement support techniques on prescribed med taking Implement support techniques during meals for non-self sufficient users Implement support techniques to help nonself-sufficient users with their bodily fucntions Implement support techniques for non-selfsufficient user in moving, walking, carrying Implement support techniques for non-selfsufficient user in dressing and grooming KEEPING CLEANING AND SAFETY

Basics of environmental hygiene

Implement environment cleaning techniques Use equipment for environment cleaning

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know how to do - SKILLS as cognitive and practical

know how to be

CONDITIONS IN DOMESTIC ENVIRONMENTS

Use products for bathroom fixture cleaning Use products for room cleaning Basics of personal hygiene

Implement hygiene techniques for user’s linens

Safety and prevention in domestic environments

Implement safety procedures in domestic environments

8.5.8 Social Guardian In Italy regions manages autonomously social services and in particular interventions for older adults in community. In some regions, specific figures manages services aimed at fostering older adults independent living, monitoring situations of fragility and empowering mental, physical and relational resources of the individual. This figure, who often attend a short course for being qualified, takes different names in different regions. In this report is presented the figure identified by Regione Liguria, the Social Guardian. He/she makes home visits or telephone calls, gives support in mobility, accompanies the older adult when going out (for shopping, visits or administrative tasks) and monitors his/her health status in order to avoid risky situations. The Social Guardian plays a complementary role with respect to the home aid provided by municipalities by monitoring frailty situations, activating territorial networks around lonely people and contributing to the reduction of improper institutionalizations. In Liguria, the Social Guardians are professionals coming from the social cooperation world, without a specific qualification, but practically trained (very short course) to perform the envisaged tasks.

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SKILLS

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know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

ENVIRONMENTAL MONITORING

COMPETENCIES know how to be

to know the basics of home environment safety

to report an environmental risk (to whom, how, with what times)

to evaluate a safety risk in home environment

to know the basics of hygiene in home environment (cleaning, food etc.)

to report an hygiene risk (to whom, how, with what times)

to evaluate an hygiene risk in home environment

to take actions to reduce the risks

HEALTH MONITORING

to know the main indicators of risk conditions for physical and mental health

to report an health risk (to whom, how, with what times)

to evaluate an health (mental and physical) risk in home environment

to take actions to reduce the risks

EQUIPE WORKING

ADMINISTRATIVE SUPPORT ACTIVITIES OF DAILY LIVING SUPPORT 6

to know the network of services which can to address the older adults to the main support older adults at local level existing services which can improve his/her quality of life to activate formal and informal support to stimulate active and healthy lifestyle to know the basics about the administrative practices related to aging management to know the basics of domestic economy

to evaluate the usefulness / necessity of activating a service to build a network around the older adult working with medical social worker, neighbors and volunteers

to support older adults in compiling fiscal practices and other administrative practices to evaluate the proper foods to be bought on the basis of economic

to go grocery shopping

Sources: 1. Agorà Social Cooperative – Social Guardian Job Description; 2. Genoa Municipality Website – Social Services – Interventions for older adults in community http://www.comune.genova.it/pages/interventi-dicomunit%C3%A0-anziani-0 3. Law - Delibera Giunta Regionale N° 218/2012 562634-EPP-1-2015-IT-EPPKA2-SSA

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availability and food needs to know the basics of nutrition principles to know the basics of physical and mental conditions of older adults during accompaniment (falls risk assessment)

to accompany in the proper way the older adult when going out

to know the basics of social participation process

to promote older adults social participation relying on his/her network and/or expanding it

8.5.9 References Boerma, Wienke, et al. Home care across europe. Case studies. Ed. Nadine Genet. London, UK: European Observatory on Health Systems and Policies, 2013. Colicelli C., La domanda di assistenza sul territorio e l’out of pocket delle famiglie: quali prestazioni di tipo infermieristico, XVII Congress of Federazione Nazionale Collegi IPASVI, March 2015 http://forumbm.it/forum/wp-content/uploads/2015/03/Intervento_Carla_Collicelli-1.pdf Genova A., Le disuguaglianze nella salute, Carocci, Roma, 2008 Lamura G., Principi A., 2009a. L’ indennità di accompagnamento. La suddivisione della spesa tra sociale e Sanitario. Giornate della Ricerca Sociale – Roma, 25 giugno 2009, “Il sistema di protezione e cura delle persone non autosufficienti. Prospettive, risorse e gradualità degli interventi”. Progetto promosso dal Ministero del Welfare, http://www.istitutodeglinnocenti.it/ eventi/pdf/roma_220609.pdf;jsessionid=AB6157AB5144061A49 8FEAA9325D0F86 Maciocco G. & Scopetani E. eds., Diseguaglianze nella salute. Lo stato dell’arte, in “Prospettive Sociali e Sanitarie” n. 11- 12/2010 Merotta V., l ruolo delle assistenti familiari nel welfare italiano, Report Fondazione ISMU – Iniziative e studi sulla multietnicità, May 2016 http://www.ismu.org/wpcontent/uploads/2016/05/Merotta_Assistenti-familiari_paper_maggio2016.pdf Law 328, 8.11.2000. “Legge quadro per la realizzazione del sistema integrato di servizi e interventi sociali” (Framework law on social services), http://www.camera.it/parlam/leggi/00328l.htm 562634-EPP-1-2015-IT-EPPKA2-SSA

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Law PSIR 2013/2015 (Regione Liguria) (Health and Social Services Regional Integrated System) Law DGR N 446/2015 (Regione Liguria) - Health and Social Services Integrated System EUROSTAT http://ec.europa.eu/eurostat IRS-Soleterre, 2015, Lavoro domestico e di cura: pratiche e benchmarking per l’integrazione e la conciliazione della vita familiare e lavorativa, Report finale, marzo, http://www.soleterre.org/sites/soleterre/files/soleterre/dettaglio/pubblicazioni/RAPPORT OLAVORODOMESTICOeDICURA_2015_SOLETERRE_IRS.pdf. ISTAT – Italian National Statistics Institute http://www.istat.it/it/ Ministry of Health 2007 – Department of Quality – National Commision for the definition and the update of the Essential Levels of Assistance (LEA) “Nuova caratterizzazione dell’assistenza territoriale domiciliare e degli interventi ospedalieri a domicilio” (New definition of home nursing), http://www.ministerosalute.it/imgs/C_17_pubblicazioni_772_ allegato.pdf, searched 10.03.2010. Italian Ministry of Health, 2010, http://www.ministerosalute.it/esenzioniTicket/esenzioniTicket.jsp Italian Health Ministry - February 22nd 2001 Agreement “Accordo tra il Ministro della sanità, il Ministro per la solidarietà sociale e le Regioni e Province autonome di Trento e Bolzano, per la individuazione della figura e del relativo profilo professionale dell’operatore socio-sanitario sanitario e per la definizione dell’ordinamento didattico dei corsi di formazione”, Official Gazette 1April 19th 2001. http://www.ipasvi.it/archivio_news/leggi/175/ACC220201.pdf Pesaresi F. 2007. “Le cure domiciliari per anziani in Italia” (Home nursing care for elderly in Italy) in Prospettive sociali e sanitarie vol. 37 n. 15 Pesaresi F. 2007a. “Il SAD per anziani in Italia” (Home help care for elderly in Italy) in Prospettive sociali e sanitarie vol. 37 n. 18. Pesaresi F., 2010. Prestazioni e pesaresi%20integrazione%20ss%202010%208%20marzo.pdf,

servizi

sociosanitari.

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9 OLDER PERSONS HOMECARE IN SPAIN 9.1 Overview on the older persons homecare service in Spain Why homecare is a basic need in Spain? It is a fact that Spanish population is a progressively aging, since nowadays people tend to live to older ages, and this increases the number of long-term old age dependents. When people analyze their choices in finding a way to be assisted in this situation of dependency, they realize that hospitalization and nursing homes often are not adequate options due to the fact that expenses are very high. In the past dependents resorted to their family and friends when in need, but due to changes in family relationships and in informal support (provided by family, friends…) this is no longer an option for most of them. Finally, when asked they express their willingness to stay at home as a personal choice. Homecare in Spain There are two sides to the services provided at home to long-term old age dependents in Spain: health and social services. HOME NURSING SERVICE This is a group of activities –previously planned- developed by professionals who are part of a multidisciplinary nursing team. The aim of this team is to provide health services by means of a series of activities which have to do with promotion, protection, healing and rehabilitation. These services are provided within a frame of joint responsibility of the patients and/or their family with the professionals of the nursing team. They are provided at the patient’s home when, due to their health conditions or to other criteria previously established by the team, they cannot get about. HOME SOCIAL SERVICES CARE This service is aimed at that group of the population with great limitations to do their daily chores, being this temporary or permanently. They help them in improving their personal autonomy and their quality of life within their environment. Among others, the users of this service are dependant elderly people, and thus they have limitations in their personal autonomy. The service may vary, and they may provide homecare, tele-home care services, catering, laundry, funding to adapt their home for accessibility, technical assistance, etc. How do laws regulate these homecare services in Spain? Here we include a summary of the most salient laws referred to homecare health and social services: • • • •

Law 14/1986, 25 April, Act on the General Health System Law 16/2003, 28 May, cohesion and quality of National Health Services Royal Decree 1030/2006, 15 September, in which the General Health System common services portfolio and the procedure for its updating are established. Law 39/2006, 14 December, to promote the personal autonomy and attention to dependents.

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•

•

• •

Resolution of April 23 2013, Social Services and Equality Secretary of State. Agreement of the Social Services Regional Council and of the System for the Autonomy and Dependency Attention on criteria, recommendations and minimum requirements for the development of prevention plans on dependency situations and personal autonomy; basic data of the information system of SAAD and Social Services Reference Catalogue. Royal Decree 1051/2013, 27 December, regulating the benefits of the System for the Autonomy and Dependency Attention, established in the Law 39/2006, of 14 December, to promote the personal autonomy and attention to dependents. Royal Decree 291/2015, of 17 April, modifying the Royal Decree 1051/2013, of 27 December, regulating the benefits of the System for the Autonomy and Dependency Attention, established in the Law 39/2006, of 14 December, to promote the personal autonomy and attention to dependents. Guide for clinical homecare good practices. Organización Médica Colegial (Collegiate Medical Organization) and Ministry of Health. 2005 Strategy for patients with chronic and polypathologic diseases care. 2013

9.2 Report on primary data about homecare service in Spain Who are responsible for the provision of homecare health and social services? Again we classify this information into two groups, health services and social services. Home nursing service •

Home nursing services are carried out nationwide, basically, by Primary Care doctors and nurses in two ways: on demand or by scheduled attention. • Other homecare strategies are developed to a greater or lesser extent depending on the Autonomous Regions, and this will depend in two factors, the specialized attention given and the primary care give: • Depending on the specialized attention given: • Home Hospitalization Units. • Depending on the Primary Care given: • Homecare Sanitary Teams. • Terminal and Immobilized Patient Service. • Continuous Care Units. • Family Carer Attention Service.

Social Services Homecare In Spain there are three administrative levels responsible for the provision of social services homecare, the State Administration, the Autonomous Regions and the Local Councils: State Administration. They are only competent at a basic legislative level. The Imserso [Elderly and Social Services Institute] is the body responsible for this. 17 CCAA [Autonomous Regions]. They have a main managing competence in terms of social services assistance. They have a total legislative capacity and the main executive functions. 562634-EPP-1-2015-IT-EPPKA2-SSA

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Local Councils. They are competent in terms of managing basic social services, no matter which administration finances them. Both local and autonomous administrations partly finance benefits, compensations and services through a complex scheme which varies from one Autonomous Region to another. In order to gather the primary data referred to the practitioners – both formal and informal –involved in elderly homecare, we have passed a questionnaire created ad hoc for this purpose. The sample of people interviewed corresponds to 105 care providers, 81% of whom have been working with elderly people for the past five years. Out of all the care providers interviewed, 41% were homecare providers or homecare assistants, 19% were auxiliary nurses, 6% nurses and 31% of the respondents marked the box other. When asked about the type of institution they worked for, 57% belonged to a public institution, 14% worked for a private company, 14% were self-employed and 14% of the respondents marked the box other. On an average respondents were born in 1970. The tasks which these homecare providers more often carry out are, among others, elderly needs assessment, home treatments -such as taking blood samples, supervision for healthy life styles or team meetings and contacts with other professionals related to elderly care. 71% of these care providers usually stay for 15’ to 30’ in each client’s home, whereas 14% of them do so for 30’ to one hour. They usually, in 71% of the cases, visit these people once a week, and two or three times a week in 14% of the cases. When they were asked about the needs of the elderly they usually have to deal with, their responses are the following: 71% of the times they need to be very respectful with the values the elderly more cherish –including religious beliefs and spiritual needs. 57% of the respondents comment on their need to try to prevent skin lesions by providing elderly with an adequate hygiene, repositioning and taking good care of the skin; care providers also need to be instructed on repositioning in order to avoid provoking bedsores and pressure sores; they also need to be educated in the specific care to be given to urinary and fecal incontinent patients; they need to be trained in helping elderly in developing a strict discipline in complying with non-pharmacologic treatments, including active and healthy lifestyles, such as adherence to prescribed diets, control of food consumption, exercising; finally, 43% of the people interviewed comment their need to be supported in supervising self-controlling physical health, in rehabilitating elderly physiological habits and in overseeing adherence to treatments –such as preparation of dosage, revision and adjustment of new doses, etc. If we exclude nurses from the care providers interviewed, 44% of the resulting group work for a public institution and 39% for a private one. On an average respondents were born in 1973. As for the tasks these care providers more often have to carry out, among others, they need to assess their clients needs. They also have to take care of the personal hygiene of the elderly as well as help them in their everyday activities. Finally they need to supervise they have healthy life styles. 31% of these care providers stay at their clients’ home for 1-2 hours, and 35% of them stay from 30’ to one hour. 46% of the respondents usually visit the elderly once a week, and from 3 to 5 times 24% of them.

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When asked about the tasks they need to take care of during their daily activity, 69% of them assist elderly in their personal hygiene –taking a shower or bath, cleaning their teeth, etc; 60% of the respondents regularly help clients dressing up and also moving around at home; finally, 56% of care providers help elderly in their house cores, i.e. cleaning, tidying up, doing the washing, ironing and organizing their laundry. We enclose, together with this document, a table in which information obtained from secondary sources has been gathered. This has been arranged in terms of the different categories implied. Who pays for homecare in Spain? As we have done before, we will first analyze this aspect in terms of the health services provided and then in terms of the social services. Nursing Services: In Spain the health system is provided almost universally by the National Health Service but individuals can also purchase private healthcare. Let’s explain this in more detail. •

Public Health System The health coverage is almost universal and tax-financed: A transfer in made from the national budget to the different Autonomous Regions. The Autonomous Regions may increase their expenses through some special items, these costs being assumed by the region’s budget.

•

Private Health Insurance This is a type of medical and nursing care provided by insurance companies that users can privately subscribe.

•

Philanthropic/ Community service Exceptional assistance on medication control, enteral feeding…

Social Services: In this country social services are run by the administration at three levels, State Administration, Autonomous Regions and Local Corporations (City Councils and Provincial Councils). The State Administration contributes to this funding through the agreed Social Security (SS) Plan, created in 1988, with the aim of developing and strengthening the SS basic network, and reducing the irregularities in the offers. This Plan is structured in different collaboration agreements signed between the State Administration and the Autonomous Regions (except for the Basque Country and Navarra). The Autonomous Regions agree to pay, at least, the same amount of money as the State Administration. Since the Dependency Law 39/2006 became effective, priority has been given to its funding (it is cofinanced by the State Administration and the Autonomous Regions). This law takes into account a wide array of services and benefits, one of them being SAD (Homecare service) This System for Dependency Attention is co-financed by: the State Administration the Autonomous Regions: agreeing to pay, at least, the same amount of money 562634-EPP-1-2015-IT-EPPKA2-SSA

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Dependent patients: in line with their financial resources The management of SAD can be hired with a private company. Homecare: tasks and activities Sanitary Services •

•

•

•

•

•

Attention to patients in acute phase Medical patient monitoring and acute illness control, as frequently as needed. Follow-up as required. Nursing attention Attention to patients with chronic illnesses Nursing attention: follow-up, signs and symptoms control, treatment control, treatment compliance, specific treatments (treatment of pressure ulcers), catheter care, control and replacement (SNG, PEG, S.V.) etc... Medical attention Post clinical attention Medical and nursing follow-up care. E.g.: ongoing care for pluripathological patients Geriatric attention Medical and nursing homecare provided to elderly patients Medical and nursing provided to elderly patients in a residence after being dismissed from hospital. Palliative care Medical and nursing care to control symptoms, medication and special techniques (paracentesis...) Home hospitalization Patients with chronic pathologies requiring complex medical or nursing techniques (such as dialysis, intravenous feeding or non-invasive mechanical ventilation) are in need of informal support (provided by family, friends…) and/or sufficient social coverage. The social coverage can be updated when the medical assistance is given.

Social Services Personal Attention Service o Personal care (persona hygiene, dressing, food, personal appearance…) o Help in getting up or getting in bed, help in mobility, in moving around the house and when going out from home. o House chores support. o Sociosanitary activities (supervision in medicines intake, supervision in adequate diet intake,…) o Assistance in personal paperwork. o Teaching how to do different household chores. Tele-home care services Home-delivered meal services 562634-EPP-1-2015-IT-EPPKA2-SSA

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Home-delivered laundry services Home cleaning services Home hairdressing services Home chiropody services Support to carers Education and involvement with family, and promotion of personal autonomy. Technical assistance to improve home accessibility.

9.3 HHCP involved in older persons homecare service in Spain: roles and competences The homecare profession Education of HHCP: In Spain, as already stated, we can classify HHCPs into two groups: informal practitioners (with no previous training) and formal practitioners (those who have previous training in care, the type of training raging from professional qualifications to university training). The professional qualifications in Spain have been categorized in the Professional Qualifications National Catalogue (CNCP), they are arranged in terms of professional groups, and in terms of level of qualification, following the EU requirements. These constitute the base to develop the titles and certificates of professional qualification offered. The CNCP includes the content of the VET associated to each qualification, according to a structure of articulated formative units. EU and national framework of qualifications: The correlation of the Spanish framework with the EQF is done through the Spanish Framework of Qualifications (MECU) or National Qualification Framework (NQF), which includes all the levels, from level 1 (primary education) to level 8 (University Doctoral Studies). As can be see in the table, the MECU is the result of the addition of the CNCP and the Spanish Qualifications Framework for Higher Education (MECES). These specifications are presupposed at level 3 of CNCP, corresponding with level 1 of MECES and with level 5 of EQF, establishing as Higher Education the one corresponding to the degree of Técnico Superior de Formación Profesional (VET Upper Level Technician). Problems faced by the homecare profession One of the problems that homecare has to face is that specialized sanitary homecare and homecare professionals are still scarce in the labor market (there is a lack of occupational therapists, psychologists, nursing assitance, psychiatric attention, physiotherapists, psychomotor activity). Also, more financing should be allotted to better prepare these professionals and to better help those in need, e.g. a quicker and more immediate attention should be given, there should be a better response capacity –a variety and adequacy of 562634-EPP-1-2015-IT-EPPKA2-SSA

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services and benefits. Professionals should also be more flexible to adapt to changes. Besides, there are great difficulties in maintaining the present system and there should be a better sociosanitary coordination. As for the conditions in which many elderly live, there is a need for homes to be adapted to the patient’s new requirements. Customers Homecare sanitary services users •

Elderly who, due to their health condition or to other criteria previously established by the team, cannot get about. Homecare social services •

Elderly with limitations to get around in their everyday life, with difficulty in their personal autonomy, dependent.

NURSES (EQF 6):

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KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

ROLE (SET OF ACTIVITIES)

■ Know and identify the structure and

RESPONSIBLE FOR GENERAL CARE.

function of the human body. ■ Understanding the molecular and physiological bases of cells and tissues. ■ Understand the use and indications of health products linked to nursing care. ■ Know the different groups of medicine, their authorisation principles, the use and guidelines, and their action mechanisms. ■ Know and asses the nutritional needs of healthy people and people with health problems throughout the life cycle, to promote and strengthen guidelines/patterns of healthy eating behaviour. ■ Identify nutritional problems of higher prevalence and choose the appropriate dietary recommendations. ■ Know the pathophysiologic processes and its symptoms and risk factors that

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■ Use of medication, evaluating the expected benefits and the associated risks and/or effects of its administration and consumption. ■ Identify the people’s psychosocial to different health situations (in particular, disease and suffering), choosing the adequate actions to provide help in them. ■ Establish an emphatic and respectful relationship with the patient and family, consistent with the person’s situation, health issue and development stage. ■ Use strategies and skills allowing an effective communication with patients, families and social groups, as well as expressing their concerns and interests. ■ Recognise life-threatening situations and know how to perform basic and advanced life support manoeuvres. ■ Apply the nursing procedure to provide and guarantee welfare, quality 111 of 418

COMPETENCIES know how to be

■ Ability to work in a team. ■ Ability to apply critical thinking. ■ Capacity for analysis and synthesis. ■ Capacity to assume an ethical commitment. ■ Ability to properly communicate verbally and nonverbally and stablish interpersonal relations. ■ Ability to recognise diversity and multiculturalism. ■ Ability to apply knowledge into practice. ■ Ability to solve problems and make decisions. ■ Ability to work on the basis of quality criteria. ■ Ability to develop creativity. ■ Ability to develop initiatives and entrepreneurial spirit.

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determine health status and diseases in the different stages of the life-cycle. ■ Know and identify physical and psychological problems derived from gender-based violence in order to train the student in prevention, early diagnosis, assistance and rehabilitation to victims of this form of violence. ■ Know and apply the principles based on comprehensive nursing care. ■ Understand the changes connected to the process of ageing and its impact on health. ■ Know the health issues that are more common in elderly people. ■ Know the Spanish healthcare system. ■ Know and be able to implement team leadership techniques. ■ Know the applicable law and the Spanish nursing code of ethics ad conduct, inspired in the code of ethics and conduct for European nursing. ■ Know the most relevant mental health issues in the different stages of the life cycle, providing comprehensive and effective care within nursing. ■ Know the palliative care and pain

and safety to the people attended. ■ Manage, assess and provide comprehensive nursing care for the individual, the family and the community. ■ Ability to describe the health primary level bases and the activities to be developed to provide comprehensive nursing care for the individual, the family and community. ■ Promote the involvement of people, families and groups in the healthdisease process. ■ Identify the factors associated with the health and environmental issues to care for people in health-disease conditions as members of a community. ■ Identify and analyse the influence of internal and external factors in the level of health of individuals and groups. ■ Analyse statistical data referred to population-based studies, identifying the possible causes of health problems. ■ Educate, provide and support members of the community’s health and welfare, whose lives are affected by health problems, risk, suffering, illness, disability or death.

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Ability in leadership. Ability to learn. Ability to plan and evaluate. Ability to adequately use IT resources and emerging technologies. ■ Ability to demonstrate research skills. ■ Ability to develop information management skills. ■ Ability to communicate in the mother tongue. ■ Ability to communicate in a second language.

■ ■ ■ ■

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control to provide care that alleviates the condition of advanced and terminally ill patients. ■ Identify the nutrients and the food. ■ Identify people’s psychosocial response to different health situations (in particular, disease and suffering), choosing the adequate actions to provide help in them. ■ Identify the different characteristics of women in the different stages of the reproductive cycle, the climacteric and the alterations that may occur providing the necessary need at each stage.

■ Identify the care needs derived from health problems. ■ Carry out nursing care techniques and procedures, establishing a therapeutic relationship with the patients and their families. ■ Choose interventions aimed at treating or preventing problems derived from health deviations. ■ Have a cooperative attitude with the different team members. ■ Identify structural, functional and psychological changes and ways of life associated with the process of ageing. ■ Choose the carers intervention aimed at treating or preventing health problems and their adaptation to daily life by proximity and support resources for the elderly person. ■ Identify the characteristics of the lead role of nursing services and care management. ■ Provide care, guaranteeing the right to dignity, privacy, intimacy, confidentiality and decision-making capacity of the patient and family. ■ Individualize the care taking into account: age, gender, cultural

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differences, ethnic group, beliefs and values. ■ Develop communication, clinical reasoning, clinical management and critical judgment techniques; incorporating in the professional practice the knowledge, skills and attitudes of Nursing based on the principles and values associated to the skills described in the general objectives and courses that make up the Degree. ■ Implement health care information and communication technologies and systems.

SOCIALAND HEALTH CARE FOR PEOPLE AT HOME

ROLE (SET OF ACTIVITIES) Domestic service assistant. Home care assistant.

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

COMPETENCIES know how to be

Home care and psychosocial support.

Observe and communicate with the dependent person to identify the need for transmitting any health information.

Carry out physical home care actions aimed at people with socio-health care needs (UC0249_2).

Home support and family meals.

Adapt and apply personal hygiene and

Carry out psychosocial home

Home hygiene and health care.

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Elderly, disabled or convalescent home care worker.

Practical training at the workplace in Social and health care for people at home.

bed making techniques at home, selecting commonly used products, materials and utensils, according to the state of the dependent person and the type of technique to be applied. Use movement, mobilization, walking and positioning techniques on the dependent person according to the level of dependence.

care actions aimed at people with socio-health care needs (UC0250_2). Carry out activities related to the management and operation of the household unit (UC0251_2).

Execute prescriptions for administering medication orally, topically or rectally, as well as local heat and cold treatments; deciding on and organizing the material that must be used according to the technique demanded and the prescription. Apply techniques to assist in eating and drinking and collection of excretions according to the level of dependence of the person, following the prescribed indications. Collaborate on the personal assistance and psycho-social support of dependent people and their family environment, applying criteria and strategies that promote their personal autonomy.

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Prepare a work plan in the home, adapting actions to the needs of the household unit. Organize and buy food, household goods and other basic products for use at home daily or weekly. Apply basic cooking techniques to make meals, according to the characteristics of the members of the family unit. Carry out the cleaning, maintain order and make small repairs in the home. Take part in the company's working processes, following the rules and instructions established at the workplace.

PHYSIOTHERAPISTS: Implementation. The public system offers these therapies in units, services and specialized Medical and from “Primary Health Care” centres. Since 1991, Physiotherapy has been legally integrated in “Primary Health Care”. In 2006 the Common Service Portfolio of the National Health System was stablished. The physiotherapy activities that are implemented in accordance with the programmes of each health service are those that could be carried out in the primary health care, on an outpatient basis, prior medical advice, including home health care by clinical circumstances or by accessibility limitations. The type of assumable activity in the old people’s home is described in the box “OCCUPATION” below. The physiotherapy centres can be public or private stated-assisted centres. Private procurement of physiotherapy at home is allowed.

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ROLE (SET OF ACTIVITIES) Prevention of development of progress of musculoskeletal disorders. Physiotherapy treatments to control the symptoms and a functional improvement in musculoskeletal chronic processes. Recovery from minor musculoskeletal severe processes Physiotherapy treatment in neurological disorders. Chest physiotherapy. Health guidance and training for the patient or carer.

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

Know and understand the morphology, physiology, pathology and behaviour of both healthy and sick people in the natural and social environment. Know and understand the sciences, types, techniques and tools on which physiotherapy is based, articulated and developed. Know and understand the physiotherapeutic methods, procedures and proceedings aimed to be both therapeutic itself to be implemented in the clinic for functional rehabilitation or retraining, and to the execution of activities targeting health advocacy and maintenance. Practical skills, knowledge of ethical and professional values of an administrative and organisational context and of the legal principles of the profession. That they are known and are able to implement both on specific clinical studies in the hospital setting and for outpatients, as in the primary health care and community care proceedings.

COMPETENCIES

Carry out Medical History of Physiotherapy. Examine and assess the functional state of the patient/customer. Establish the Physiotherapy diagnostic. Provide effective and comprehensive care. Assess the development of results Elaborate the physiotherapy medical discharge report. Interact in an effective way with the multidisciplinary team. Conform to the limitations of their professional competence. Show respect towards the work of others. Spread the ability to motivate others. Incorporate ethical and legal principles and the social and community aspects in decision making. Update the knowledge, skills and attitudes. Sustain a learning attitude. Focus the performance on evidencebased practice. based Express a high degree of self-concept.

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know how to be Design, management and implementation of the physiotherapy intervention or treatment. Coordination of the Physiotherapy Intervention Plan. Cooperation with other professionals. Physiotherapy services management. Development of quality in the practice of physiotherapy. Elaboration of care protocols. Intervention in the field of development, prevention, protection and health recovery. Incorporate scientific research into the own sphere of the physiotherapy field.

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Position the patient/customer un the centre of the actions. Intervene in protection and promotion of health. Intervene in disease prevention. Show discretion.

OCCUPATIONAL THERAPISTS The majority of specifications that are described below are described for the occupational therapist degree that are general for all the education plans in Spain. Some specifications have been removed since they will no longer be taken into account in a home environment for elderly people. Implementations: The public system offers these therapies in units, services and specialised centres. The care at home often arises from the need to adjust the strategies and skills in the real environment of the patient, during the transition of medical discharge from medical short-stay units, medium-stay and long-term stay. In any case, this care at home is scarce or a bit more frequent from the private sector. ROLE (SET OF ACTIVITIES) The one specific of occupational therapy

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

Interventions in geriatric rehabilitation. Interventions in Mental Health rehabilitation. Interventions in intellectual disability. Interventions in neurological rehabilitation. Interventions in physical rehabilitation.

COMPETENCIES

Assess the abilities and the individual’s physical, psychological, sensory and social problems. Develop treatment plans and training to attain the highest level of independence and autonomy possible in daily life. Carry out, assess and register

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Interventions in psychosocial rehabilitation. Interventions in palliative care. Interventions in burns.

empowerment and training tasks. Practice intervention using techniques, procedures, methods and models, through the use of the profession in the environment. Adapt the environment. Recommend and adapt support products. Adapt technical aid, orthoses and prostheses. Implement routines and planned habits that facilitate the recovery or development of new roles. Implement the knowledge and proceedings in the inpatient, outpatient ad community settings, whether it is through health care, social care or social health care. Forward information, ideas, issues and solutions to both customers and specialised people. Focus and emphasize the intervention of family members and carers in the “task facilitating role” of the person in order to avoid “the person’s substitution in the performance of tasks” Ability to gain new knowledge and skills.

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Empowerment of the individuals to conduct those tasks that enhance the ability to participate, contributing to recovering from their disease and/or facilitating their adaptation to their disability. Change of the environment so it can strengthen the participation. In teaching and research: Training for family members and carers in Adaptation to the demands and expectations of the affected person and the family to the reality of their daily life. Incorporation of attitudes and professional and ethical values that develop the ability to integrate the acquired skills and knowledge.

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SPEECH THERAPY Most of the specifications for the Degree in Speech Therapy that are included here are common to all the Spanish curricula. Orofacial-Myofunctional Therapy is of great importance in the field of neurological and neurodegenerative disorders, as well as in ageing. Mater Degrees and Specialized Courses with non official recognition are taught. Implementation: The public system offers these therapies in specialized units, services and centers; they also offer them in non-specialized centers. Homecare resources are scarce; it is only offered on a private basis and relatives of patients need to actively look for it.

ROLE (SET OF ACTIVITIES) Communication and orofacial functions.

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

Expressive and/or comprehensive oral speech functions; Articulation and oral speech disorders no matter what the cause is. Reading and writing disorders. Tympanostomy tube disorders; Phonation, speech and diet disorders related to pathologies referred to orofacial –myofunctional alterations no matter what the cause is. Orofacial functions provoking alterations in articulation and speech.

COMPETENCIES

Stimulating communicative, expressive / comprehensive oral/written speech functions. Orofacial –myofunctional stimulation in speech, voice, language, breathing and swallowing, derived from brain damage. Setting up alternative or augmentative communication systems. Central and peripheral facial paralysis treatment. Training in voice functional and/or organic alterations (presbycusis, vocal cord paralysis). Rehabilitation of orofacial structures and functions in tracheostomized patients and/or laryngectomees.

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know how to be

Prevention, evaluation and treatment of expressive / comprehensive oral/written speech abnormalities. Prevention, evaluation and treatment of otorhinolaryngological pathologies. Prevention, evaluation and treatment of neurological diseases related to communicative pathologies and to orofacial functions.

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9.3.1 REFERENCES Royal Legislative Decree 1393/2007 of October 29, which establishes the organisation and planning of official university education. (Boletín Oficial del Estado, número 260, de 30 de octubre de 2007). Order CIN/2134/2008, of July 3, which establishes the requirements for verification of official university degrees for the practice of the Nursing profession. (Boletín Oficial del Estado, número 174, de 19 de julio del 2008). Agencia nacional de Evaluación de la Calidad y Acreditación (National Agency for Quality Assessment and Accreditation of Spain). Libro blanco. Título de grado de enfermería. Zaragoza; 2004.

10 OLDER PERSONS HOMECARE IN FINLAND 10.1 Overview on the older persons homecare service in Finland The population in Finland is ageing more rapidly than in any other EU country. From the total 5, 487 308 inhabitants (1.4.2016) number of people aged over 65 years is 19,9 % (www.stat.fi, 11.4.2016). In addition, Finland’s economic situation aims to economy efficient. The working age population started to decrease in 2010 and the old-age dependency ratio will be the highest of all EU countries up to 2025. This is mainly due to longer life expectancy. People live longer but also maintain their functional abilities and independence longer. Both of these tendencies are expected to continue in the future. (EQUIPII, 2012: 42.) The number of clients in home care was 72 531 (November 2014), 66 % of them was women. The number of customers rose by 0.5 per cent from the previous year. However, in Finland 11,8 % of the total number of population over 75 years were clients in home care. 40,4 % from all clients in home care have 1 – 9 visits during November 2013. Quarter of the clients needs more as 60 visits during a month. (http://www.julkari.fi/bitstream/handle/10024/126302/Tk05_2015.pdf?sequence=1) Most older people prefer to live in their own homes before institutional care (EQUIP II, p 42). Both groups, clients and professionals, highly valued resource-based home care, including elements of encouraging and supporting everyday activities (Turjamaa 44). Home care is more affordable and is considered to be of higher quality than institutional care (SuPer, 2015). The aim of Finland’s policy for older people is to promote their functional capacity and independence, with the intention that as many older people as possible could continue to live in their own homes and their familiar environments. Functional capacity can be maintained and improved with a range of sufficiently early and wide-ranging preventive and rehabilitative activities. Social relations and networks of older people are important. The Finnish social and health policy is based on a universal welfare principle where the public sector (the state and the municipalities) are in charge of providing well-being services for all citizens. In financing the welfare state, Finland is undergoing a transition to a new phase due to changes in the age structure of the population.

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Finnish homecare is regulated by following legislations and recommendations: The constitution of Finland requires that the government guarantees sufficient social and health care services to all; The act on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons and by Quality recommendation. The Ministry of Social Affars and Health is responsible for the drafting of legislation concerning home care and home services, their general planning and guidelines. Municipalites are tasked with the organization of social and health care services. A good one half of municipal expenditure is used on the provision of social and health care services. Roughly half of this is financed with taxation, a quarter with customer fees and sales and nearly a fifth with state subsidies. One third of the statutory expenditure is covered with state subsidies. Customer fees cover just under a tenth of the total costs. The home care services a customer receives are based on his/her individual needs. In Finland, municipalities have a legislative responsibility to organize home care services in collaboration with the private and third sectors, as well as with older clients, to plan and realize home care services consisting of support for older clients at home by offering care and services based on clients’ personal needs (Act on electronic processing of patient documentation in social and health care 159/2007, Act on supporting the functional capacity of the older population and on social and health services for older persons 980/2012). The Finnish Ministry of Social Affairs and Health first published the National Framework for High-Quality Services for Older People in the year 2001 and published an updated, more detailed version in 2008. This framework was a new tool for informative guidance for municipalities. (EQUIPII, 2012: 43.) The municipalities are responsible for services for older people, including home care services. Municipalities may produce services themselves or purchase them from private or third-party service providers. Outsourcing services increase rapidly in services for older people. 1.1.2019 the system of the social and health care in Finland will change radically. In Finland, home care services consist of three main service providers as formal care: municipal home care services, the private and third sector (Act on supporting the functional capacity of the older population and on social and health services for older persons 980/2012) and informal care as realized by family members. Home care services are organized by home help service units (under social welfare) and home nursing units (under health care) either separately or together. Home care services consist of domestic help, including personal and physical care (e.g. meals on wheels, bathing and electronic alarm service) (Social welfare act 1301/2014), and care based on nursing (e.g. taking care of medication and wound care) (Public health act 1326/2010). New opportunities support clients and their participation to choose a server of home care. Home care provides services for older people that support independent living at home and to maximize clients’ resources. This requires home care services to make possible meaningful activities and social relationships in relation to the quality of life and psychological well-being of the older client despite their decline in functional, cognitive, psychological and social abilities and the need for the highest level of care (Act on the status and rights of patients 1992, Act on supporting the functional capacity of the older population 980/2012). (Turjamaa, 2014: 11-12.) According to the current act (Act on supporting the functional capacity of the older population and on social and health services for older persons 980/2012) in Finland, every client who regularly receives home care services has a right to have an individual and valid care and service plan. In addition, they have a right 562634-EPP-1-2015-IT-EPPKA2-SSA

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to participate in decision making and decisions have to be made in agreement with older clients (Act on the status and rights of patients 1992/785, Act on the status and rights of social welfare clients 812/2000). Home care professionals have a legislative obligation to produce and document a care and service plan for all home care clients (act on supporting the functional capacity of the older population and on social and health services for older persons 980/2012, Act on electronic processing of patient documentation in social and health care 159/2007). Professionals’ work is guided by professional codes of ethics for each profession (The Finnish nurses association 1996, The Finnish union of practical nurses 2012). (Turjamaa, 2014: 13.) The roles and responsibilities of the private and the third sector vary in different services. The private sector’s care and services consist of residential homes, service housing with 24-hour assistance and home care services realized in clients’ homes. The third sector’s care and services consist mostly of home care services in older clients’ homes (Private health care act 152/1990, Private social services act 922/2011). Available services are similar for all clients without acknowledging potential individual variations (Turjamaa, 2014: 13). Care and services comprise two fields: long-term care, including 24-hour institutional care provided by health centres and based on medical justifications (Act on supporting the functional capacity of the older population and on social and health services for older persons 980/2012), and home care services, including residential homes with 24-hour assistance, service housing and care and services in older people’s homes with 24-hour or part-time assistance. In residential homes and service housing, older people live in their own or shared rooms and can purchase services according to their needs (National institute for health and welfare 2012b). 6.6% of municipal home care service clients received 24-hour institutional care in Finland (National institute for health and welfare 2012b). In 2010, 8.7% of people aged 75 years or older lived in residential homes or service housing (National institute for health and welfare 2012b). (Turjamaa, 2014: 13 – 14.) Home care services consist of regular home visits, and the content of services is counselling and support for self-care, everyday activities and available services. Home care professionals provide personal assistance for everyday activities such as hygiene, eating and dressing and nursing treatments such as the administration of drugs and wound care (Social welfare act 1301/2014). Additional auxiliary services, such as meals on wheels, transportation and assistants, are also organized (Social welfare act 1301/2014). (Turjamaa, 2014: 13 – 14.) 5.3% of municipal home care service clients received home care services in Finland (Official Statistics of Finland 2013). The average age of clients in regular home care was 79.4 years and a total of 53,703 (76.2%) clients were aged 75 or over. In most cases, the older clients’ need for home care was assistance with everyday activities related to personal care and housing, and 64.7% received auxiliary home care services regularly (National institute for health and welfare 2012a). Over half (51.9%) of home care service clients received regular home visits, whereas 41.2% received between one and nine visits in one month and more than a quarter (25.3%) of clients had over 60 visits a month (National institute for health and welfare 2012a). (Turjamaa, 2014: 13-14.) In home care, the goal is to help, guide and support clients in coping with their normal daily activities. The care is performed in cooperation with clients and their families at homes and in different units within the social and health care sector. In many municipalities, home care services are provided 24 hours every day. Good communication, interaction and ethical skills are required in home care work, along with domestic and nursing skills. It underlined the primacy of promoting health and welfare, of giving priority to 562634-EPP-1-2015-IT-EPPKA2-SSA

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prevention and support for home living, and of the comprehensive assessment of individual needs. (EQUIP II, 2012: 42.) Older people’s home care services are realized in clients’ homes by home care professionals (practical nurses, home care nurses, public health nurses and home care service managers) in collaboration with other social and health care professionals. Most of the home care workers are practical nurses. Altogether there are 25 000 home care workers in Finland, almost 99 % of them are women (EQUIP II, 2012: 42.) Approximately 130,000 people in Finland have a cognitive disorder and 40,000 of them are living at home (Ministry of social affairs and health 2012), while near to 8000 of them are living at home with regular home care services (National institute for health and welfare 2011). Cognitive disorders are the most significant predictor of long-term care among older people: 95% of longterm institutional care clients and 60% of home care clients have some cognitive disorder. Other common diseases among older people (75+ years) include diseases of the circulatory system, musculoskeletal disorders and diseases, malignant tumours and diabetes. Projections of other disabilities show that the number of older people with limited mobility will increase by 70% from 2000 to 2030 if the agegroupspecific proportions stay the same as in the years between 1980 and 2000. (Turjamaa p 12-13)

10.1.1 Challenges of the Finnish home care The professionals in the research of Turjemaa (2014: 44) reported that the focus of daily care was on everyday activities was based on clients’ physical needs. They characterised the care as repeating similar activities from day to day, home to home and client to client. Work was mechanical, performancebased and standardized. The results of this study are similar to those indicated by previous studies, where task orientation, illness-centred approach and being solely focused on clients’ physical resources have been found to characterise professionals’ work with older people (Hayashi et al. 2011, Salguero et al. 2011). Both clients and professionals saw meaningful and inspirational activities as the most important elements for promoting clients’ living at home. (Turjamaa, 2014: 44.) The current planning for older clients’ care is classification-based with an instrument-oriented approach where there is a lack of acknowledgement of clients’ individual needs and resources. In addition, classification-based documentation seems to be inflexible and hides the full picture of the client’s situation. Current home care is organisationally-driven and the context of care is mainly routine-like help in everyday activities, based on doing things on behalf of clients and ignoring their personal perspectives, individual needs and resources. (Turjamaa 48) By the results of Turjamaa (2014) showed elements that promote older clients living at home based on clients’ individual skills and abilities as highlighted by home care services. One essential question concerns the factors that contribute to older clients’ living at home. As populations are ageing, it is evident that organisationally-driven and passive home care is causing increasing public health and financial concerns (Hammar et al. 2008, National institute for health and welfare 2010). Additionally, because of their availability, home care based on available services cannot respond to the challenges provided by care that promotes clients’ living at home for as long as possible. Caring for clients in their own homes takes place in a different context to hospitals and is one that requires a different approach. 562634-EPP-1-2015-IT-EPPKA2-SSA

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An interesting finding in the study of Turjamaa (2014) as well in Questionnaire for HHCP (2016, CARESS) was that both older home care clients and home care professionals were very positive and interested in the study and supported the development of home care when they had the possibility to tell their opinions about the aspects of home care that should be developed. The professionals assessed realistically their own working methods and the organization of home care services as a whole. Especially professionals realistically assessed their current working methods as task-oriented, routine-like and based on a philosophy of ‘doing on behalf of clients’ (Turjamaa 2014: 44). With active and efficient rehabilitation and support of psycho-social functional ability is possible reduce the need of home care and in some cases even clients won’t need homecare at all. In Finland in some areas such kind of projects and interventions which have made good results and also reduced costs in public homecare services.

10.1.2 References Erkkilä, Sari: ’Asiakkaat ovat ihmisiä – eivät prosentteja’, Selvitys superilaisten työstä kotihoidossa ja kotihoitotyön kehittämisestä. SuPer, Helsinki, 2015. Salonen, Kari – Kinos, Sirppa (Eds.): Good Practices and Visions of the Future of Home Care Work in Bulgaria, Finland, Greece and Turkey. Based on the EQUIP II (2010 – 2012). City of Turku, Education Department and Turku Vocational Institute, 2012. Taipale-Lehto, Ulla – Bergman, Timo: Competences and Skills Needs in Services for the Elderly. Publications 6, Finnish National Board of Education, Helsinki, 2015. THL: 2014. http://www.julkari.fi/bitstream/handle/10024/126302/Tk05_2015.pdf?sequence=1. 11.4.2016. Turjamaa, Riitta: Older People’s Individual Resources and Reality in Home Care. Publications of the University of Eastern Finland, Kuopio, 2014.

10.2 Analysis of activities, skills and competences of home health care practitioners in Finland 10.2.1 MATERIAL AND METHODS Purpose of the study The CARESS project will target the problem of skill mismatch in the field of elderly homecare by intervening on a number of causes at national and European level. Purpose of this study was scarce definition of the specific roles of each home health care practitioner (HHCP) and scarce definition of skills which should characterize each HHCP.

Method The questionnaire was developed by Caress –project. The questionnaire contains all together 67 items including background questions, items regarding of activities home health care practitioners (HCCPs) actually provides in elderly clients’ home and items of skills and competences of HCCP. The skills and 562634-EPP-1-2015-IT-EPPKA2-SSA

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competence levels are self-evaluated by HCCPs. The questionnaire contains also open end questions. The questionnaire was translated in finnish and the questions were modified to taking in consideration of finnish home care work environment. The questionnaire was sent as SurveyPal mode via e-mail to members of Super (Finnish Union of Practical Nurses).

Sample The questionnaire was send to (N= 2550) persons, whom are working in the homecare sector according to Finnish Union Practical of Nurse (SuPer) membership registry and who have got at least the VET education on EQF4 level. The response rate was 17 % (n= 433). Almost all of the responders (98,8 %) had more than five years of work experience in older adult homecare. 27 % of responders had more than 20 years of work experience over all. Majority were working in the public sector/municipalities (98,8 %). The respondents were practical nurses (99,5 % ) in professional background and most of them were female (94,9 %) in the age group between 36 – 50 years (36,5 % )(Table 30) Variables

n =%

Gender Male Female Age (years) 63 Occupation Practical nurse Home helper Registered nurse Public health nurse Something else Activity as practitioner Municipalities Public institutional homecare Private homecare provider Freelance professional activity Other (EKSOTE, OIVA etc.) Employment years 20 years

5,1 94,9 1,6 30,5 36,5 28,9 3,0 0,0 99,5 2,5 0,7 0,5 2,3 98,8 0,2 0,7 0,0 0,9 3,7 22,2 21,2 25,9 27,0 100%

Table 30: Socio-demographic characteristics of the home health care practitioners (n=433)

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10.2.2 RESULTS Time and regularity of the visits The HHCPs spend average 15 – 30 minutes per visit at the older person’s home (72,7 %) and do visits 2 – 3 times in the week with the same client (42,5 %). 30,9 % of the clients needs 4 – 5 visits and (14,8 %) 6 – 7 visits and (14,5 %) more as 7 visits per week. Once a week visits are scheduled for (6,2 %) clients. (Figure 23) In open end questions the respondents answered that the time lenght of visits are based on the clients’ needs. Some of the clients need visits lasting only few minutes to 15 minutes, while the others may need 45 to 90 minutes per visit. It was also mentioned that visits that last over two hours are rare, but possible. The time spent with the client depends of the clients care needs, service plan, content of the visits (taking blood samples, administering medications like injections, assisting in personal care such as helping with intimate hygiene and eating) If the client have a shower day it takes usually approximately an one hour.

The fact of the amount of the clients to visit per shift also have effect on how much time home care professionals have to spend in each client. Nurses shifts (ie morning or evening shift) effects to some extent as some of the respondents mentioned that during the weekday there is much more time to spend than on a weekend or in the evening shift, when the visiting time at client’s home is from ten minutes to an half hour. The phone calls to clients takes about five minutes of working time.

onc e

6,2 % 42,5 %

2- 3 tim es

30,9 %

4- 5 tim es 6- 7 tim es

14,8 %

Mor e

14,5 %

0,0 %

20,0 %

40,0 %

60,0 %

80,0 %

100,0 %

Figure 23: The average amount of the visits with same client per week (Once 6,2 %, 2-3 times 42,5 %, 4-5 time 30,9 %, 6-7 time 14,8 %, more than 7 14,5 %)

Activities carried out in elderly clients home According to the results the most common activities the home health care practitioners carry out in older person home are assistance in activities of daily living (99,3 %) (Table 2) and supporting 562634-EPP-1-2015-IT-EPPKA2-SSA

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clients to perform these activities independently. Assistance in activities of daily living include assistance in personal hygiene, dressing, eating and drinking and assistance in toilet. (Table 2). The vast majority of HCCPs did administering and assessing medications to the clients (99, 3 %) (Table2). This included administering different types of medications (eye drops, nose drops, injections e.g klexane, insulin) and dispensing oral medicines into pill dispensers.

HCCPs (93, 9%) evaluated clients health condition during the visits and (86, 6 %) of them gave guidance and education in health management and lifestyle. According to the answers to the questionnaire (Table 2) and the open end question answers the clinical nursing procedures that HHCP`s carried out in home care were taking measurements (blood pressure, blood sugar and weight), taking samples for lab tests (e.g. INR, CCMSU), taking care of nutrition via peg-feeding, exchanging stoma and ostomy bags, putting on compression stockings (96, 5 %), wound care (92,6 %) (e.g assisting in NPWT= negative pressure wound therapy, assisting and skin care with cystofix catheter, nefrostomy and tracheostomy), biliary drainage care, removing stitches. The respondents mentioned also helping the clients with oral health, providing psychological support, terminal care and running the clients’ errands (e.g walking the dog).

In rehabilitation the HHCPs were involved mostly by doing walking exercises with the clients (71, 1 %) and the least regularly (31, 5 %) in doing memory exercises with the clients (Table 2). They also helped the clients to implement the contracts made by physiotherapist to exercise in home. This included assisting, supporting and guiding the clients to do exercises in home environment (e.g chair exercise, exercise with weights or rubber bands) for gaining the muscle strength and balance training. HHCPs also help clients with the use of different aid and ancillaries.

In open end questions results was found out that the HHCPs were also using as a method of rehabilitation to support client`s self-management skills in everyday life (rehabilitative shopping, help with clients` everyday activities) In respondents opinion they didn`t have enough time to do the memory tests or take clients for a walk during the day. The respondents were concerned of the fact that when the HHCPs have a limited time, the work can easily slip into helping the clients too much, without assessing clients ‘abilities to do their own care independently and encouraging them to do more by themselves. Also the psychosocial support needs to be take into consideration. (82, 5 %) of HCCPs were taking care of safety at the clients home (Table 2). 562634-EPP-1-2015-IT-EPPKA2-SSA

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Cooperation with the clients’ relatives was mostly advising of relatives (92 %) The HCCPs also worked in with the multi-disciplinary teams (74%) Reporting of the activities was done by 90, 2 % of the responders % Clinical activities related to assessment and planning evaluation of customer needs evaluation of health condition RAI measurements in-home health exams personal assistance planning Social/Environment/Education companionship, support and assistance in social relationships intervention for a proper prescription and use of principals devices in home environment guidance and education in health management and lifestyle. Information about different social services Support and assistant in different things Support to independence Assistance in personal hygiene (bathing, grooming, etc.) Assistance in dressing house management and cooking positioning and supporting mobility Assistance in toilet Assistance in proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home Taking care of safety at home Clinical activity related to therapy pharmacological treatment and homeostasis maintenance, performance relating to excretory functions Wound care Stoma care Need of technical support with external devices: catheterization Putting aid dressings or compression stockings Skin treatment and care Something else Rehabilitation approach Walking exercises Memory exercises Position of the treatment Supporting to independency and ability to function Something else

60,0 93,9 26,5 34,3 41,6 67,2 50,0 86,6 51,9 44,0 99,3 97,7 95,3 89,5 97,4 77,9 82,8 99,3 92,6 58,4 70,7 96,5 97,0 12,1 71,7 31,5 43,6 95,5 10,7

The skills and competences HCCPs need in home care

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In the questions regarding skills and competences needed in home care the responders were asked whether they need this skill and competence in their work and in which level their skills and competences were in their own opinion. They were also asked where have they gained the skills and competences (education or in work).

The results showed that according to the HCCPs they need for example general knowledge, skills and competence in medical knowledge specifically related to the profession (85, 5 %) and (58, 9 %) thought this skill and competence was in good level. They had gained this in both education (59,8 %) and in work (60,5 %). (Table 31). All the answers regarding different skills and competences, skill levels and where gained (percentage of answers) are shown in (Table 31).. List of detailed percentanges of answers see (Appendix 3).

In general responders evaluated that they need lots of basic theory knowledge (mostly over 70 %) of various subjects (Table 3) to be competent professionals. They didnt find that they need skills of cooking (39,0 %) or skills of using ICT for social participation (40,1 %) as such much. Also competence in procedures for providing physical therapies (41,1 %) was not so highly regarded by responders. In most of the items of questionnaire the responders evaluated that their competence was on average or high level. (Table 31).

Competencies for terminal illness support (31,3 %) and grief support (25,2%) of the responders evaluated themselves on low level. Competences for evaluating customer mental health status was also quite low (21,6%) of evaluated this on low mastery level. Knowledge of services and social benefits was also found on satisfactory level by (20,2%) of respondents. Highest competence level was on competence in assisting on personal hygiene (65,6 %) of responders evaluated themselves on high level. Competences for collaborating with other practitioners the HCCPs (81,6 %) have gained mostly by working and competence in basics in anatomy and pathology (79,9 % of responders) have gained mostly by attending a school, training course or academic course. Also basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc. were primarly gained in school or in training (75,1 %).

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COMPETENCE

IS THE COMPETENCE REQUIRED?

SELF-EVALUATE THE LEVEL YOU MASTER THE COMPETENCE

YES answers

Low Mastery Average Mastery High Mastery] 3,3 % 58,9 % 34,3 16,1 % 61,4 % 17,3 % 0,2 % 32,6 % 61,2 % 5,2 % 36,5 % 48,5 % 3,7 % 51,5 % 39,6 % 2,8 % 51,6 % 39,3 % 22,4 % 50,1 % 16.8 % 5,6 % 57,0 % 30,7 % 30,0 %

Basic medical knowledge specifically related to my profession Basics in anatomy and pathology

85,5 %

Environmental and personal hygiene basic concepts Basics in home economics

82,1 %

Basics in dietetic

78,6 %

Basics in older person’s healthy lifestyles

75,5 %

Basic psychology elements

60,8 %

Basics in domestic safety and prevention

76,3 %

Basics in social-health services organizations and networks

73,5 %

80,6 %

65,8 %

COMPETENCE ACQUIRED ATTENDING A SCHOOL, A TRAINING COURSE OR AN ACADEMIC COURSE YES

COMPETENCE ACQUIRED BY WORKING PRACTICE

59,3 %

60,5 %

79,9 %

37,1 %

53,5 %

65,6 %

34,4 %

71,7 %

72,5 %

45,9 %

63,3 %

52,8 %

70,2 %

39,2 %

48,1 %

66,5 %

36,8 %

72,4 %

YES

52,9 % 10,5 %

Knowledge about the main aids and devices for older and disabled people Basic on the main characteristics of peoples with different levels of autonomy Basics in law and human rights frameworks

78,3 %

8,9 % 56,5 % 27,8 %

29,7 %

79,9 %

44,7 %

24,0 % 50,6 % 8,8 %

28,5 %

58,9 %

71,4 %

70,5 %

35,1 %

Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Other specific basic medical procedures

84,4 %

27,6 % 52,2 % 11,5 % 3,3 % 42,0 % 49,0 %

75,1 %

54,3 %

9,2 % 57,5 %

51,7 %

69,8 %

78,3 %

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related to my profession Procedures for providing medical therapies

84,6 %

25,5 % 3,0 % 39,9 % 53,1 % 29,2 % 44,4 % 6,5 % 10,1 % 58,0 % 19,2 % 0,5 % 28,8 % 65,6 % 2,1 % 53,4 % 39,2 % 4,2 % 35,7 % 41,1 % 8,9 % 49,9 % 29,8 % 5,9 % 54,9 % 29,8 %

74,6 %

54,3 %

41,4 %

53,0 %

40,6 %

58,0 %

55,5 %

59,0 %

48,3 %

69,7 %

32,9 %

55,8 %

52,9 %

50,6 %

50,0 %

59,4 %

5,6 % 51,8 % 36,8 % 14,4 % 53,9 % 18,4 % 19,3 % 54,7 % 9,4 % 17,5 % 39,2 % 17,5 % 10,6 % 51,2 % 29,7 % 20,2 % 56,0 % 15,8 %

34,7 %

77,3 %

24,2 %

75,5 %

22,2 %

71,7 %

25,7 %

58,0 %

33,7 %

75,0 %

27,1 %

79,5 %

85,1 %

2,8 % 50,0 % 41,2 %

69,2 %

50,2 %

80,0 %

3,6 % 41,0 % 49,8 % 14,6 % 55,7 %

49,0 %

69,0 %

24,1 %

75,5 %

Procedures for providing physical therapies

41,1 %

Procedures for environmental hygiene

57,3 %

Procedures for personal hygiene

78,5 %

Procedures for customer moving

78,6 %

Cooking

39,0 %

Procedures for defining an eating plan

60,1 %

Procedures for monitoring healthy lifestyles Managing errands Usage of reporting and monitoring tools

69,0 %

Procedures for fostering customers going out of home Fostering customers social and familiar relations Using ICT for social participation

61,6 %

Using ICT for health status monitoring

79,5 %

Providing the customer with contextualized and personalized information about the network of services he/she can rely on Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Competences for caring with dignity

74,8 %

Competences for managing conflicts

67,2 %

82,9 %

57,3 %

40,1 %

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Competences for collaborating with other practitioners Competences for coordinating the work of other practitioners Competences for working in a group /equip /staff Competences for evaluating customer needs and adapting the service Competences for evaluating customer mental health status Competences for empowering the customer Grief support

79,5 %

Competencies for terminal illness support

65,2 %

Competencies for supporting the customer in building up an independent living path

81,9 %

52,8 %

69,0 %

81,2 %

75,8 %

71,2 %

66,8 %

19,3 % 6,1 % 56,8 % 30,4 % 24,8 % 45,8 % 7,5 % 17,5 % 44,1 % 22,0 % 8,9 % 55,3 % 28,7 % 21,6 % 52,2 % 17,6 % 9,0 % 61,0 % 18,3 % 25,2 % 46,1 % 16,5 % 31,3 % 37,9 % 12,9 % 4,2 % 51,4 % 38,0 %

27,4 %

81,6 %

22,4 %

61,4 %

18,2 %

72,3 %

29,9 %

80,7 %

43,5 %

71,1 %

26,0 %

75,0 %

36,2 %

66,8 %

48,0 %

56,5 %

39,2 %

78,4 %

Table 31: Competences needed in home care (percentages of given answers)

Assessing the older persons needs According to the results (74, 8 %) of HCCPs of this study did not normally participate in the first definition of the older person’s care needs and (66, 7 %) didn’t formalize in the sheet, a chart or a report the initial evaluation of older person’s needs. However (68, 6 %) of responders participated in the definition of a personalized homecare plan of the clients as their care process continued and evaluated (90, 3 %) in elderly needs in order to possibly refine the homecare plan according to changing situations. The (93, 3 %) of HCCPs reported the clients implement care. The responders (87, 5 %) thought that they have the proper competencies to evaluate older person’s needs and build a personalized homecare plan.

In open end questions answers the responders (13, 9 %) who didn’t evaluate to have enough competence to build a personalized homecare plan brought out that they don’t have enough time to learn necessary IT programs actualize the care plan to patient files. They also didn’t have enough time to do all the paper work as they have too many care visits to do per shift with aging clients with cognitive and psychological disabilities. Because of the limited time, HHCPs thought it was hard to get to know the client and to have the clients’ trust and to take care of them holistically. ”It is hard to do the assessment when you haven`t even met the client” one respondent answered. That is also effecting for the quality of the care. 562634-EPP-1-2015-IT-EPPKA2-SSA

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Some of the respondents didn’t know, how to make and document the care and service plan for the home care clients, because usually the registered nurse or public health nurse are responsible for the planning, taking care and evaluating the care and service plan. The form of documentation of the care and service plans also vary. One respondent was saying that they don`t have clear form for the care and service plan. Methods to do the care and service plan also varied depending municipalities. In one respondent’s opinion, she would have the skills to do the care and service plan, if she only had the authorization.

According to some of the respondents, doing night shifts, having a part-time job, being a student were all influencing the fact that they didn`t have skills for doing and assessing care and service plan. Some disclosed that they don`t have proper introductions for doing assessing and care and service plans.

In general respondents answered that they need more education and experience for assessing the care planning. Some of the HHCPs that answered that they didn’t have skills to do the care and service plan to the clients, were also mentioned, that they didn`t have the knowledge enough to do the care and service plan. In their opinion, they didn`t have enough the knowledge how to get the background information; assess the clients` demographic history, health status (including functional and cognitive status), living conditions and recognizing the social relationships. This is the result from rarely visits to the client as well as the lack of time.

10.2.3 DISCUSSION Home health care practitioners carried out mostly the following activities at clients home: assistance in activities of daily living, evaluating clients health condition, various clinical nursing procedures and administration and assessing medications. In Finland practical nurses are authorized to dispense and administrate medication by oral route after qualification from formal education and gaining authorization by passing exams in their work place. (Act on Health Care Professionals, 28 June 1994/559, National Supervisory Authority for Welfare and Health 2016). HCCPs also supported clients’ rehabilitation by different methods and worked in multi-disciplinary teams and took care of safety at clients home.

The results indicated that the activities HHCPs carried out were in line with the national legislation of home care services in Finland. According to the laws, the national government has a supervisory role mainly by law and information steering systems. Different laws are related to home care and its organizational and financial structures. The important law; Social Welfare Act requires the services that municipalities must produce and it includes the home help services. The act on supporting the functional capacity of the older 562634-EPP-1-2015-IT-EPPKA2-SSA

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population and on social and health care services for older people (980/2012) defines that every client who regularly receives home care services has a right to have an individual care and service plan. Laws on health care, primary health care and specialized medical care cover health services. There are also few separate laws on occupational health care, mental health services and the prevention and treatment of infectious diseases, and the status and rights of patients which includes the right to participate in the care planning. Act on care services for the elderly ensures that elderly people will receive care and treatment according to their individual needs. The act also specifies the responsibilities of local authorities and must be drawn up without unnecessary delay once the older person`s service needs have been investigated (Ministry of Social Affairs and Health 2012; 2016, Genet, Boerma & Rissanen 2010). Home care services consist of domestic help including personal and physical care such as meals on wheels, bathing, electronic alarm service (Social welfare act 1301/2014) and care based on nursing such as taking care of medication and wound care (Public health act 1326/2010).

The results indicated that majority of responders thought that almost all the competences included in questionnaire used in this study are required in working in home health care. In self –evaluation of HCCPs skills and competences level, the responders evaluated their competence level satisfactory in knowledge of social- and health service system inc. social services and benefits client is entitled to Knowledges, skills and competences were also evaluated mostly in categories of satisfactory or good in procedures for providing physical therapies, fostering clients social and familiar relations, competences to support for coordinating the work of other practitioners, competences for evaluating clients mental health status and competences for caring clients with terminal illness and grief support.

Presumably HCCPs self-evaluated low competence level in hospice care (i.e. terminal care) and supporting grieving process was due that in Finland home health care service is not usually involved in hospice care and care of dying at home. According to Social Affairs and Health Ministry in Finland statistics year 2008 only 10 % of over 75- year old persons died at home (Pihlainen 2010). Still most of the Finnish people would like to die at home. (hyväkuolema.fi 2016). One of the obstacles for hospice care at home or reason for discontinue it at home were that relatives caring for the dying patient weren’t coping mentally or physically. (Pihlainen 2010). It was also found out that in practical nurses’ basic education didn’t contain enough lessons of hospice care (i.e only couple of hours) (Pihlainen 2010). In spring 2009 a discussion was conducted at the Ministry of Social Affairs and Health in Finland on the need to develop hospice care in Finland and recommendations for hospice care were made. The recommendations emphasize the human dignity and right of self-determination of the dying individual. A good hospice care requires competence of the care staff and maintenance of their wellbeing at work. Hospice care is to be organized according to the patient’s wish either in the patient’s home or in an institution. Specialization training in hospice care for 562634-EPP-1-2015-IT-EPPKA2-SSA

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nurses and practical nurses should be started as soon as possible according to this recommendations. (Pihlainen 2010).

Even the curricula of Practical nurses Vocational Qualification in Social and Health Care (2010) includes the basic nursing of patients mental health and drug abuse diseases and promoting the client or patient’s physical and mental health, security and wellbeing. (National Board of Education 2010). It seems that skills and competences in this area are not sufficient enough. Maybe the focus of the home care work is also based on physical care needs and clients clinical condition than the mental status. (Turjamaa 2014). HCCPs had acquired competence mostly by working practice in following skills: basics in social-health services organizations and networks, knowledge about the main aids and devices for older and disabled people, procedures for fostering customers going out of home, providing the customer with contextualized and personalized information about the network of social services and benefits he/she can rely on, competences for collaboration with other practitioners and competences for evaluating customer needs and adapting the service. Competences in basics in anatomy and pathology, basic procedures in medical assistance (eg. make injection, provide drugs, change medication) HCCPs have gained mostly by attending a school, training course or academic course.

HCCP didn’t take a part of the first evaluation and forming a clients’ care and service plan. This is probably the reason why they evaluated their knowledge of social services and benefits lower than expected. However HCCPs were involved in modifying and assessing clients care plans in continued care. Yet they thought that they could have competences to do it, if given time, education and authorization. It seems that in division of tasks in home care doing the care plans especially on beginning of the care of the new client is done by the registered nurses or registered public health nurses.

In Finland a Vocational Qualification in Social and Health Care (practical nurse education) include education of planning and implementing care plans. The practical nurse education may also include Home care and nursing of the elderly as an elective module through the student’s personal study plan. Then a student must have passed at least Nursing and Care (30 competence points) in a skills demonstration test, prior to embarking on this elective module. In vocational upper secondary education, the module gives 15 competence points. If student chooses The care for the elderly as competence area the curricula contains the skill requirement of ability to plan, implement and assess the care of and service to the elderly, take their resources and participation into account. (Finnish national board of education 2010).

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In conclusion to be made of the results are tentative due methodological weaknesses such as the reliability of the questionnaire can be compromised. The future education needs for the Home health care practitioners are hospice care, evaluating clients mental health, knowledge of social services and benefits and planning and implementing care and service plans.

10.2.4 References Act on Health Care Professionals, 28 June 1994/559 (Laki terveydenhuollon ammattihenkilöistä, 28.6.1994/559). Visited on 17th May 2016. http://www.finlex.fi/fi/laki/ajantasa/1994/19940559

Genet N, Boerma W & Rissanen S. 2010. Finland p.86-98. In Genet N, Boerma W, Kroneman M, Hutchinson A & Saltman RB. Home care across Europe. Case studies. http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf (Visited on 16th May).

Finnish national board of education 2010. REQUIREMENTS FOR VOCATIONAL QUALIFICATIONS Vocational Qualification in Social and Health Care Ministry of Social Affairs and Health. 2016. Legislation: http://stm.fi/en/social-and-healthservices/legislation

Ministry of Social Affairs and Health 8.11.2012. Vanhuspalvelulailla turvataan laadukkaita palveluita iäkkäille koko maassa [visited 16th May] Act on care services for the elderly to ensure high standard of quality nationwide, http://stm.fi/en/article/-/asset_publisher/alderslagen-tryggar-hogklassig-service-foraldre-i-hela-landet

Professional practice rights. National Supervisory Authority for Welfare and Health (Valvira) http://www.valvira.fi/web/en/healthcare/professional_practice_rights

Pihlainen. A (2010). Terminal care recommendations based on expert consulting. Ministry of social affairs and health in Finland.

Ten questions of dying. Hyvä Kuolema.fi http://www.hyväkuolema.fi/category/kyselyt/

Turjamaa, R. 2014. Older people’s individual resources and reality in home care. University of Eastern Finland, Faculty of Health Sciences Publications of the University of Eastern Finland. Dissertations in Health

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Sciences 255. . [Cited 2016 April 10]. Available from http://epublications.uef.fi/pub/urn_isbn_978-952-611616-7/urn_isbn_978-952-61-1616-7.pdf

10.3Home care clients’ perceptions of quality of care and staff competence Objectives: To know the actual activities carried out at the elderly home by Home Health Care Providers (HHCP) and to know the needs perceived by the elderly, their priority and which of them are fulfilled by the service in their view. This study also aimed to know elderlies opinion about further activities that should be performed or activities that should be improved and to know the elderly satisfaction level Sample and methods: Nine elderly home care clients, aged between 80 and 97, answered semi-structured questionnaires Results: The activities that HHCP normally carried out in the elderly`s home were categorized in eight categories: Health promoting activities, Administration and assessing medications, Assistance in activities of daily living (IADL), Clinical nursing interventions, Domestic help, Assistance in application of social allowances and benefits, Rehabilitation activities and Support and assistance in social relationships. In this study activities were mostly focused on nursing procedures and administering and assessing medications which was also mentioned to be the most important priority care need to the clients in their own opinion. Despite the importance of this care need, clients assessed the HHCPs competence level only satisfactory or even poor. All in all the clients (78%) thought, they had received help needed. Clients` opinion about further activities that should be performed, the clients indicated that they would like to have more time for discussion (33%), walking tours (22%) and shopping (11%) with the HHCPs. Conclusions: The results show that in the future, HHCPs education needs has to be considered in the categories of administration and assessing medications and ethical skills. Also interaction skills as well as the HHCPs ability to plan the care needs individually and giving enough time for the client, are important aspects. HHCPs spent on average from 30 minutes to one hour in client`s home, which in some way may reflect the clients` need of the discussions with HHCP`s. Furthermore the stability of the staff should also be considered.

10.3.1 Purpose of the study Demographic ageing is one of the most serious challenges Europe is facing. Better care and sustainability of health services calls for innovative ways to address the needs of the elderly. Supporting homecare, i.e. care provided by professionals within users’ own homes, has been identified by EC as a possible solution. Although a high number of elderly and their families are searching for skilled practitioners they often have to face a mismatch between the skills they are asking for and those offered by job-seekers. The CARESS project will target this skill mismatch in order to overcome it. The project will pursue the following objectives at national and European level: a) definition of the specific roles of each HHCP b) definition of skills which should characterize each HHCP 562634-EPP-1-2015-IT-EPPKA2-SSA

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c) definition of VET pathways/curricula that HHCPs should attend to get skilled in elderly homecare; d. definition of HHCP career pathways d) recognition of qualifications and consequent enhancing of labour mobility; e) Integration of the above defined information about HHCP in national/local occupational profiles and VET curricula. The above mentioned objectives will be pursued through a number of activities including gathering background data by interviews and semi-structured questionnaires by the end-users as elderly home care clients. In Finland semi-structured interviews of the elderly home care clients were carried out by project members in Omnia. The interview form was made by CARESS –project and it was translated in Finnish. The aim of this study was 1. to know the actual activities carried out at the elderly home by HHCPs, 2. to know the needs perceived by the elderly, their priority and which of them are fulfilled by the service in his/her view, 3. to know elderly opinion about further activities that should be performed or activities that should be modified/improved, 4. to know the elderly satisfaction level

10.3.2 Material and methods Sample Nine elderly homecare clients participated in this study. Eight of the participants were woman and one man. The mean age was 87,7 years, the youngest was 80 and the oldest 97 years old. Participants lived mostly in town centre (n=6), Three lived in rural area (table 1).

Variables

n = 9 (%)

Gender Male Female

1 (11,1) 8 (88,9)

Age 80-84 85-89 90-94 95-99

2 (22,2) 4 (44,4) 2 (22,2) 1 (11,1)

Living environment city rural

6 (66,7) 3 (33,3)

Table 32: Socio-demographic characteristics of the home care clients (n = 9)

Data collection Open semi-structured interviews were made with nine 80-97-year-old elderly home care clients in their own home. The youngest was 80 years and the oldest 97 years old. Among the clients, there was one married couple. Most of the interviews were collected by interviewer present face to face in the interviewees own homes and one was done via phone. Interviews were done in February-March 2016. Participants were known to interviewers beforehand by relations or other ways. Home Health Care 562634-EPP-1-2015-IT-EPPKA2-SSA

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Practitioner was present in two of the interviews. The interviews were structured by questionnaire made especially for this purpose in Caress project. Data analysis The interviews were analyzed using qualitative content analysis. At first the answers of the interviews were read to get first impression of the content. Then the text was categorized in the meaning-units corresponding to the aim.

10.3.3 Results TIME SPENT WITH THE CLIENT HHCPs service time recipients at home was on average from 30 minutes to one hour (44%). It also varied from 15 minutes (22%) to 30 minutes (33%), but nobody had the caregiver at their home for more than 1 hour. Clients received on average the visit of caregiver in their home more than 7 times per week (56%). One client was visited once a week and one client received a visit from 5 to 7 times per week. One couple was visited once in every other week. ACTIVITIES CARRIED OUT ELDERLY HOME BY HHCPS Activities carried out in elderly`s home by HHCPs were divided in eight categories: Health promoting activities, Administration and assessing medications, Assistance in activities of daily living (IADL), Clinical nursing interventions, Domestic help, Assistance in application of social allowances and benefits, Rehabilitation activities, Support and assistance in social relationships. The results of the interviews showed that the activities that HHCP normally carried out in the elderly`s home were more focused on nursing procedures like assistance in activities of daily living (IADL) (n=5) and administering and assessing medications (n= 9). Health promoting activities included assessing clients care needs, assessment of functional capacity, health education of clients and their relatives, disease prevention, assuring home security and safety phone. 33% of the clients had assessment of the care needs and 56% had evaluation of their health condition. Personal assistance planning was provided for 22% of the clients. HHCP was monitoring healthy lifestyle and preventing illness according to 44% of the interviewed clients. Home Environment assessment in terms of safety for example testing the safety phone, fire alarm and assisting in technical aids such as rollator, wheelchair were assisted by six (67%) of the clients. Education in health management and lifestyle was provided in 33% of the clients. Administration and assessing medications included assessing, planning, implementing and evaluating medical drug therapies as well as educating clients about their medical drug regimens. Administering and assessing medications was normally carried out in every client`s home by HHCP. This included for example taking care of client`s diabetic medication, dispense medicines and monitoring the impacts of medicines. 44% of the clients had assistance in the prescription. Assistance in activities of daily living (IADL): Activities of daily living included personal hygiene (bathing, grooming and oral care), clothing (the ability to make appropriate clothing decisions and physically dress oneself), eating (the ability to feed oneself though not necessarily to prepare meals), maintaining continence - both the mental and physical ability to use a toilet, mobility at home (moving oneself from seated to standing and get in and out of bed). The clients were mostly assisted in daily living (ADL), such as 562634-EPP-1-2015-IT-EPPKA2-SSA

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personal hygiene (56%), toilet use (33%) and assistance with feeding (33%). HHCP also assisted clients` in clothing (22%) and transferring (11 %) although it was not so common. Assisting clients with mobility at home such as positioning and supporting mobility’s or doing some rehabilitation activities were carried out by HHCP in 33 % clients. In addition some of the clients (33%) got support to daily activities (shopping, going to a medical appointment, etc.). The HHCPs provided also Clinical nursing interventions such as wound management (22%) and chronic wound management after surgery (11%), monitoring clients respiratory, blood pressure (89%) taking blood samples (22%), applying compressive stockings (11%), stoma care (11%). Domestic help offers daily housekeeping services (including laundry) and preparing meals. Assistance in cleaning the home was provided for some (44%) of the clients (for example cleaning a toilet, dusting, changing sheets, washing dishes, taking out the garbage). Assistance in application of social allowances and benefits. This includes giving information to clients of home care allowances and requirements for these allowances and also helping clients filling out the forms. This category was carried out with 44% of the clients. Rehabilitation activities includes assistance of ancillary tools and supporting clients’ rehabilitation. Supporting mobility or doing some rehabilitation activities were carried out by HHCP in 33 % of the clients. 44% clients had assistance in the use of principals’ tools in home environment (crutches, wheelchair, blood pressure measurement machine, etc.). Support and assistance in social relationships: Interviews showed that assisting, guiding and encouraging clients to take part of social activities for example day care centers were familiar to. 56% of the clients had support and assistance in social relationships Companionship such as giving psycho-social support and discussion with clients were not provided by HHCP. One client had support every day with opening television and radio or getting the newspaper.

CARE NEEDS AND PRIORITY OF THE CARE NEEDS The clients were asked about, whether the care needs were met by the home care service. Seven of the nine clients, who participated the study applied `yes` to this question. One applied `no` and one didn`t answer the question. In conclusion 78% of the clients had their need fulfilled. The most important care need the clients brought up as a priority was administering and assessing medication (67%). Other important needs were blood samples taking by Home Care, to be helped in getting out of the house, clinical nursing interventions including taking blood pressure, stoma care, wound care, assisting in daily living (hygiene, incontinence care, nutrition, rehabilitation), taking care of psychological wellbeing. When asked about further needs, the clients indicated that they would like to have more time for discussion (33%), walking tours (22%) and shopping (11%). Some actions do avoid the loneliness or social isolation. One of the clients answered that is not getting enough services from public health care, and therefore buying some services from private sector. The clients also hoped for the stability of the staff so that the same HHCPs would take care of them as to provide continuous care relationship.

COMPETENCE AND SKILLS OF THE PRACTICAL NURSES

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In general the clients were satisfied for the services Home care provided. They were using expressions like `excellent` and `good` and ratings were from six to ten in the scale of one to ten (table 2). Interaction between the client and HHCP were described as friendly or close (67%) and interaction was also mentioned to be professional (56%). The HHCPs were described to be very polite and treating the clients respectfully as always asking clients opinion. However it was mentioned that interaction varied a lot between different HHCPs. Otherwise two of the clients described interaction very distant or lacking and criticized that the HHCPs who provided the care are constantly changed. Some of the clients had some bad experiences that nurses were very busy, intimidating and even have been working under the influence of the alcohol.

Clients` opinions of the home care services

HHCP recognizes the needs for help and services Feeling of being helped Important assistance needs are taken into account primarily Interaction between HHCP General satisfaction with home care services 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Totally disagree

Disagree

Uncertain

Agree

Totally agree

Table 33: Clients` opinions of the home care services

The clients were asked to mention to consider abilities that should be fundamental for a homecare worker to have. To ability to listen the client, to be emphatic, friendly, calm, determined, reliable, to have sense of humor. Professional skills were also mentioned, for example competence in drug therapy. Domestic skills as ability prepare meals and making coffee. Ability to assess the clients’ heath condition in hole. A worrying result was that administrating and assessing medications skills were satisfactory or even poor. One married couple answered, that the medication skills were good, but on the other hand, they meant registered nurses as well. Clinical nursing skills were said to be good as skills assisting activities in daily living although there was variation in skill level depending on the HHCP. Clinical nursing skills were said to be good as skills assisting activities in daily living although there was variation in skill level depending on the HHCP. The clients’ perceptions of the ethical competencies were mostly satisfactory level or it was varying. It was mentioned that knowledge was mostly excellent but it was also varying between HHCPs. Although the clients were using domestic care services, none of them mentioned it when asked about competence and skills of HHCPs. The clients were asked to mention three things that HHCP provides that improve the quality of their life and helps them in managing in their own home. There were helping activities in daily living (hygiene, nutrition), medication (56%), measurements (blood pressure), clinical nursing activities (stoma care),

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support client`s in performing their errands (e.g. pharmacy, shopping), rehabilitation, maintain the social relationship for example helping to visit the spouse in nursing home or taking part of social activities.

10.3.4 Discussion According to these interviews HHCPs carried out mostly following activities in elderly clients’ home: Health promoting activities, Administration and assessing medications, Assistance in activities of daily living (IADL), Clinical nursing interventions, Domestic help, Assistance in application of social allowances and benefits, Rehabilitation activities and Support and assistance in social relationships. These activities are in line of services that are provided by public health services normally. Finnish municipalities have a statutory obligation to provide and arrange health and social services which includes homecare services (Paljärvi et al 2011). In Finland the Social Welfare Decree (607/1983), §9, the way that home-help services are organized is defined: 1) assistance, personal attendance and support provided at home by a trained home helper for house aid for an individual or a family and 2) auxiliary services (meals on wheels, maintenance of clothes, bathing, cleaning, transportation and services promoting social interaction. (AlzheimerEurope) For example the Department of Social Services and Health Care of Helsinki City Home care services support customers living at home in the daily functions that they cannot manage by themselves. Such functions include eating, bathing, dressing, getting up from the bed or a chair, walking and toilet visits. Home care customers can also receive health care and medical treatment in their homes if these services cannot be reasonably organized in any other way (City of Helsinki). In Paljärvi study (2012) was also found that activities home health care mostly provided were, administering and assessing medications, clinical nursing interventions and discussions with clients. The results of the interviews showed, that administering and assessing medications was one of the activities that HHCPs routinely carried out in the elderly clients´ home. Administration and assessing medications was also brought up as the most important priority care need to the clients in their own opinion. Concerning result was that, in this activity clients assessed the HHCPs competence level only satisfactory or even poor. Weak interaction skills and ethical skills as some HCCPs appearing intimidating and not listening elderly clients’ needs and wishes was also a result that should be taken into consideration in health care organizations and education. According to Salermo`s study (2011) of practical nurses` (n=200) pharmacological skills, the results showed that the greatest skill deficiencies in pharmacotherapy were related to basic knowledge about medication, and drug interactions and adverse drug reactions. The findings of Turjamaa (2014) study showed that clients and professionals described medication as one of the most major things to take into consideration in care planning. This emphasis was also visible in care and service plans. Nevertheless, especially from the perspective of professionals, taking care of medication was mechanical and instrumentally orientated in terms of administration of drugs instead of monitoring the effectiveness or adverse effects, which were noted only in three care and service plans. Interviews showed that time spent with the client was on average from 15 minutes (22%) to one hour at the most. According to clients, some nurses were very busy and the clients wished for more time spent with them; to have a dialog, discuss and take walks. According to Paljärvi et all (2011) studies, results are in line with other Finnish studies that have explored the impact of integration on homecare quality and identified that nurses are too busy and have lack of time for the client. In this study clients also wished for caregivers’ stability, so that the same HHCPs would be taking care of them continuously. In Paljärvi (2012) follow-up study continuity of the home care declined and only 35 % clients responded that they have had same home health care provider visiting them in last six months and only 16 % assessed that home health 562634-EPP-1-2015-IT-EPPKA2-SSA

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care providers are not in hurry. Also in Turjamaa (2014) study, the interviewed clients found that the first step needed to take in order to promote their living at home is having the same nurse care for them continuously. The clients described that having the same personal nurse makes it possible for them to create a familiar and confidential relationship with them. Based on professionals’ opinions, a personal relationship makes it possible to take into account individual resources and habits of the clients. However, when asked in general the clients in this study were satisfied for the services Home care provided. They were using expressions like ”excellent” and ”good” and ratings were from six to ten in the scale of one to ten (table 2). Also in Paljärvi (2012) follow-up study participants, home care clients (n = 66 84) and relatives (n = 73 -7 8) were quite or very satisfied of home care received. There was much variation in quality of the care depending on HCCP. Interaction skills, professional skills and competence were described by clients verbally in scale very poor, lacking to excellent. In Turjanmaa (2014) from home care clients’ perspectives, routine-like activities of daily living revealed predominantly hasty and restless behavior of practical nurses. It is concerning that home health service is not able to provide constant level of care. It would be important to be able identify HCCPs, who need further education and training to quarantine good level of care every day to all the clients. In this rather small study with compromised methodology the results showed that, in Finland the HCCPs education needs seemed to be in categories of administration and assessing medications and ethical skills. In Turjanmaa`s study (2014) summary of results indicated that living at home for as long as possible also requires a care relationship that is founded on reciprocity and a safe care context.

10.3.5 References AlzheimerEurope. Country comparsions of Home Care Finland.http://www.alzheimer-europe.org/Policy-inPractice2/Country-comparisons/Home-care/Finland. Visited 10.4.2016 City of Helsinki. Social services and health care. Elderly services. Home care –Internet pages. http://www.hel.fi/www/Helsinki/en/socia-health/elderly/home/ Visited 8.4.2015 Paljärvi Soili. 2012. Homecare in change, A 15-year follow-up study in the organisation, content and quality of homecare in the City of Kuopio. Doctoral thesis. Universtíty of Eastern Finland Paljärvi S, Rissanen S, Sinkkonen S, Paljärvi L. What happens to quality in integrated homecare? A 15-year follow-up study. International Journal of Integrated Care. 2011 June 15; 11. [Cited 2016 April 8]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178800/ Turjamaa, R. 2014. Older people’s individual resources and reality in home care. University of Eastern Finland, Faculty of Health Sciences Publications of the University of Eastern Finland. Dissertations in Health Sciences 255. . [Cited 2016 April 10]. Available from http://epublications.uef.fi/pub/urn_isbn_978-952-611616-7/urn_isbn_978-952-61-1616-7.pdf Salermo E. Primary nurses` knowledge of geriatric pharmacotherapy. 2011. Master`s thesis in gerontology and public health. University of Jyväskylä. [Cited 2016 April 8] Available from https://jyx.jyu.fi/dspace/bitstream/handle/123456789/27151/URN:NBN:fi:jyu2011061310989.pdf?sequence=1 )

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10.4 HHCP involved in older persons homecare service in Finland: roles and competences Occupation

ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

HHCP1 PRACTICAL NURSE

Home-help services mean performance of or assistance with functions and activities related to housing, personal care and attendance, and other conventional functions and activities in normal daily life.”

Legal framework Nursing documentation (RAI, plan for care and services) Ethics for the professional field of action Living environment of elderly people, Safety measures Standards of Hygiene Deprivation of personal liberty, Sexuality and shame Anatomy and physiology, Relevant disease patterns Nursing aids, Personal care Emergency situations Disease patterns of memory diseases and their causes Steps of the nursing process Knowledge of the most common pharmaceuticals and their administration, reliable sources of information, e.g. Pharmaca Fennica or pharmaceutical databases, Knowledge in terminal care. Knows how to apply different forms and methods of

Helps and supports clients to manage their daily activities

Plans, implements and assesses the care of and services to the elderly, taking their resources and participation into account

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Provides basic daily health care and nursing (caring and nursing) Rehabilitory approach

Observes the client or patient’s vital functions, sensory functions, ability to function and well-being.

Implements pharmacotherapy, rations and administers pharmaceuticals and monitors their effect

Evaluation of the ability of function and services need of the older person

Measures the client or patient’s body temperature, respiratory frequency, pulse, blood pressure and blood sugar correctly and recognizes changes in the client or patient’s condition.

Personal care skills

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Actively guides the client and his/her family in the use of pharmaceuticals, competence in pharmacotherapy

Supports and guides social well-being Competence in different pharmaceuticals, regulations and provisions concerning pharmacotherapy and the limitations and requirements set by them Cooperation with relatives, families and

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communication in response to varying situations with older people and their relatives Assistance in home economics, nursing and social care sector Conflict and stressful situations Complaint Management Prophylactic measures Importance of exercise as basis of independence and self-care options Food and liquid balance, Diets Functional limitations due to age and disease Personal and unique process of dying and death Establishing relationships with relatives Laws and regulations in work safety Knowledge about service system of social and health care Knowledge of income security

measures Apply nursing aid and care techniques Take measures in daily routine to ensure independent living Document observations and measures in the nursing documentation Carry out tasks in the implementation of individual activities with the elderly Integrate activities of everyday life to preserve and promote mobility and independence Apply care aids to promote physical activity , fall prophylaxis and shift of position Use ergonomic movements Document food and drink balances Apply measures to prevent infection Set individual aids appropriately (e.g. visual aids, electronic reading aids, hearing aids ) Report physical and emotional changes Take measures for first aid in emergency situations Cooperate with relatives and social networks Use communication channels to deal with conflict and stressful

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others Expertise in environment hygiene Competence in personal hygiene Promotes the elder’s life quality, monitoring the healthy lifestyle Problem solving competence Finds different solutions also to challenging situations. Work in multi-disciplinary team., team working skills Uses communication channels to deal with conflict and challenging behaviour Shares appropriate information with health professionals, other team members and key stakeholders. Teamworking by mobile devices Terminal care. Facing death. Participates in the care of a dying elder in every respect. Evaluation of the mental health of the older person Interact in a dignified way Show respect and tolerance Regard the particular personality and the

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HHCP2 PUBLIC HEALTH NURSE

HHCP3 REGISTERED NURSE

specialised care/technical nursing and coordination and supervising service provision. specialised care/technical nursing and coordination and

situations Ensure the quality of Service Perform work flow using the technology and equipment according to the situation Guides and advices the old persons and their relatives Promotes the rights and diversity of individuals

social environment of the individuals Hold the independence and self-care ability in high regard Reflect their role and actions and take feedback from the team Take cultural, religious and individually designed living and living areas into account Handle aids and private objects carefully Reflect experienced violence and its impact on their own professional actions under guidance Accept instructions Respect the privacy Take the person being cared for seriously Be patient and understanding (insightful) with regard to effects of age and disease Assist and support individuals to use alternative and augmentative communication systems Understands and follow of work safety principles

3,5 – 4,5 year polytechnic education

planning of service plan

Evaluation of service needs

3,5 year polytechnic education

planning of service plan

Evaluation of service needs

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supervising service provision. HHCP6 Rehabilitory PHYSIOTHERAPIST approach OCCUPATIONAL THERAPIST

3,5 year polytechnic education

Rehabilitory approach

PRACTICAL NURSE (EQF4) ROLE: content of the work/sets of activities HOUSEHOLD WORK

PERSONAL CARE AND ACTIVITIES IN NORMAL DAILY LIFE

theoretical and/or factual SKILLS as cognitive and practical KNOWLEDGE Living environment of elderly people Offer assistance in the relevant areas in the context of a resourceSafety measures oriented and active care and housekeeping (cleaning, taking care of clothes )

Rehabilitory approach Standards of Hygiene

Legal framework Nursing documentation (RAI, plan for care and services) Ethics for the professional field of action

COMPETENCE information and assistance in administrative matters, etc.

Offer assistance in the relevant areas in the context of a resourceoriented and active care and housekeeping Helps and supports clients to manage their daily activities Ensure the quality of Service Perform work flow using the technology and equipment according to the situation

information and assistance in administrative matters, etc.

Personal care skills

Steps of the nursing process

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ROLE: content of the work/sets of activities

SUPPORT BY OUTDOORS MOVING AND ABILITY TO FUNCTION

theoretical and/or factual KNOWLEDGE Deprivation of personal liberty, Sexuality and shame Anatomy and physiology, Relevant disease patterns Nursing aids, Personal care Emergency situations Disease patterns of memory diseases and their causes

SKILLS as cognitive and practical

general knowledge about physiology and functions, Rehabilitory approach

supporting a person's by outdoors activities (by going to shop, bank etc administrative matters) Carry out tasks in the implementation of individual activities with the elderly Apply care aids to promote physical activity , fall prophylaxis and shift of position

COMPETENCE

being Work in multi-disciplinary team., team working skills Promotes the elder’s life quality, monitoring the healthy lifestyle Problem solving competence Finds different solutions also to challenging situations.

works by guidance of home care nurse and follows the caring plan

Understands and follow of work safety principles

Use ergonomic movements FUNCTIONING AND INDEPENDENT LIVING

Knowledge of income security Laws and regulations in work safety

Rehabilitory approach Take measures in daily routine to ensure independent living

Knowledge about service system of social and health care and other service producers

Integrate activities of everyday life to preserve and promote mobility and independence

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ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

NURSING ASSISTANCE

Anatomy and physiology, Relevant disease patterns Nursing aids, Personal care Emergency situations

Provides basic daily health care and nursing (caring and nursing) Implements pharmacotherapy, rations and administers pharmaceuticals and monitors their effect Measures the client or patient’s body temperature, respiratory frequency, pulse, blood pressure and blood sugar correctly and recognizes changes in the client or patient’s condition. Perform scheduled preventive measures Apply nursing aid and care techniques Take measures for first aid in emergency situations

works by guidance of home care nurse and follows the caring plan

COMMUNICATION AND GUIDANCE

Knows how to apply different forms and methods of communication in response to varying situations with older people and their relatives

Cooperate with relatives and social networks Guides and advices the old persons and their relatives Promotes the rights and diversity of individuals

guides the client and his/her family, makes the caring plan together with client and her/his family

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ROLE: content of the work/sets of activities

MONITORING AND REPORTING

theoretical and/or factual KNOWLEDGE

Knows different ICT programs, especially client program Knows the correct levels of different things like body temperature, pulse and so on.

SKILLS as cognitive and practical Understands and follow of work safety principles Document observations and measures in the nursing documentation Document food and drink balances Report physical and emotional changes

COMPETENCE

follows the caring plan

Measures the client or patient’s body temperature, respiratory frequency, pulse, blood pressure and blood sugar correctly and recognizes changes in the client or patient’s condition.

PHARMACEUTICALS ASSISTANCE

TERMINAL CARE

Knowledge of the most common pharmaceuticals and their administration, reliable sources of information, e.g. Pharmaca Fennica or pharmaceutical databases,

Teamworking by mobile devices Document observations and measures in the nursing documentation

works by guidance of home care nurse and follows the caring plan

Implements pharmacotherapy, rations and administers pharmaceuticals and monitors their effect

Knowledge in terminal care.

comforting of client

Personal and unique process of dying and death

Show respect and tolerance

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ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

EVALUATION OF THE MENTAL HEALTH OF THE OLDER PERSON

Knowledge of most common mental changes of older person

SKILLS as cognitive and practical

COMPETENCE

Regard the particular personality and the social environment of the individuals Hold the independence and selfcare ability in high regard Reflect their role and actions and take feedback from the team Take cultural, religious and individually designed living and living areas into account

guides the client and his/her family, makes the caring plan together with client and her/his family

Promotes the rights and diversity of individuals

Uses communication channels to deal with conflict and challenging behaviour Finds different solutions also to challenging situations. Personal care skills

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11 OLDER PERSONS HOMECARE IN AUSTRIA 11.1 Introduction to older persons homecare service in Austria As of January 2013, 8,4 Milion people were living in Austria according to final results of Statistics Austria. Life expectancy at birth stands at 81 years, one year above the OECD average of 80 years and the 18.3% of the population is aged 65 or over in 2014 with a predicted rising trend in the ageing process over the next decades. Increasing longevity and declining fertility rates are expected to double old-age dependency ratios to reach 50% by 2060, so Austria has to face the challenge of rapidly increasing demand for long-term care. In the Austrian context, the role of the public authorities is divided in several levels of statutory power, and regulated by one federal and 9 different Lander laws. The state is federal, with powers shared between federal and 9 provincial governments. Federal competencies are implemented uniformly in all provinces (Länder), while provincial competencies are different among themselves. While the federal government is predominantly responsible for designing and providing allowances, each province also takes part in setting allowances levels. The Austrian system benefits include: benefits in cash (federal cash benefits, respite care benefits, 24-hour care), benefits in kind (see below), and benefits for carers. Planning in the Austrian health-care system is largely input-oriented and is – in accordance with the fragmentation of responsibility – carried out and implemented by a variety of stakeholders. In principle, plans for hospitals are made by the Länder on the basis of a national plan, and plans for general and specialist care by physicians are made by the regional health insurers in agreement with the chambers of physicians (location-based capacity plans on the basis of national guidelines from the Federation of Austrian Social Security Institutions). Since 2008, healthcare planning includes rehabilitation and ambulatory care, as well as long-term care, where it interfaces with health-care provision. In addition, long-term care plans exist at the Länder level. The medium-term goal for planning in the health sector is “needs-based planning”, where need is calculated according to morbidity statistics. For long-term care, legally the responsibility of the Länder, “need and development plans” are drawn up between the federal government and the Länder on the basis of the relevant agreement in accordance with Article 15a of the Federal Constitutional Law. The goal is to secure an adequate and varied offering of home-based care and nursing services, as well as inpatient and mixed facilities for individuals in need of long-term care. These plans take into consideration ambulatory and home-based services (social, medical and nursing provision), mixed facilities (e.g. day- and night-care centres) as well as inpatient care (care homes, homes for the elderly, shared living arrangements for the elderly, etc.), and also regulate facilities for coordination and cooperation (e.g. administrative districts for social and health-care). Similarly to regional structural plans, need and development plans are very diverse, and aimed at problem areas specific to each Land.

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In Austria, family care for older people with long-term care needs has long been provided almost exclusively by women and unremunerated. More recently, rising labour-market participation of women and growing mobility have put this traditional model of care under considerable pressure. In 2005, approximately 400,000 family caregivers – often burdened by their professional, personal and care tasks – needed respite, support and social security. Some provisions targeting these issues have been introduced over the past two decades: social insurance contributions for carers, enhanced care counselling, care leaves for employed carers, extensions of day care and other support facilities. They have been supplemented by payments of social security contributions for carers, but this support remains only a minor incentive for family carers. In 2014, an additional measure was introduced to facilitate care leaves for employees who care for a family member that is entitled to the long-term care allowance. For up to six months the carer is entitled to the equivalent of the unemployment benefit (55% of previous wage). Still, as care episodes are often extending beyond this period, about 15% of family carers are reducing or completely abandoning employment, and are often confronted with high barriers to re-enter the labour market. Despite these limitations, support to family carers has allowed numerous older people to remain in their homes, in no small part because the care provided by families can be supplemented with community-based formal care services: 37% of Austrians consider professional care at home affordable, placing the country considerably above the European average of 31% (European Commission, 2007). Long-term care allowances are shaping the Austrian system of long-term care from care in homes to care at home. Notwithstanding these improvements, fragmentation at the interfaces between formal and informal care, and health and social care, remains the main barrier to deinstitutionalisation in Austria. Social care and health care system in Austria The legal and organisational framework is still characterised by a strict division of competences and financing. A large variety of regional regulations affects the organisation and practices of residential care homes and professional education standards. Decentralisation, an inherent effect of the Austrian division of competences based on the principle of subsidiarity, is often a hindrance to coordinated action. In practice, cooperation between acute care and providers of follow-up treatments and long-term care services is limited. Despite the growing awareness of the need to integrate care and a series of efforts implemented to improve the situation, coordinated health and social care projects have not moved past the model phase. Social care services are cross- sectional matters. Both the in-patient sector of health and social care (hospitals, nursing homes, residential homes, etc.) and home-based social services are mainly subject to provincial legislation and administration. The federal state must only pass elementary laws in this area, whereas the provinces have the authority to pass and responsibility to implement laws (Art. 12(1) B-VG). The Austrian long-term care system relies on a combination of cash and in-kind benefits to users, built around a comprehensive system of long-term care allowances (OECD, 2005). This so-called Pflegegeld is funded through general taxation by the federal government with the aim to improve possibilities for independent living in case of care need. With regard to the benefits in cash, it is allowed to use them, either to purchase formal care services from public or private providers or to reimburse informal care giving. Additionally, provinces are required to provide places in institutions, in day/night care centres and home care services. The social security scheme 562634-EPP-1-2015-IT-EPPKA2-SSA

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covers the difference between recipient’s income (including care allowance) is not sufficient to cover the costs of care services. There are several kinds of benefits in cash: According the federal Long Term Care Allowance Act (Bundespflegegeldgesetz, BPGG) introduced in 1993: all persons in caring need can receive federal cash benefits. These benefits are entirely financed from taxes and they are granted to dependent persons on the basis of seven categories of need, thus the number of hours of nursing care per month. The minimum-requirement (level 1 benefit) is a monthly 60-hours need of care and an expected duration of the need that exceeds 6 months. The allowance, which varies from EUR 154.20 (level 1) to EUR 1,655.80 (level 7) per month is provided regardless of income and assets. Dependent persons who are not covered by BPGG (essentially disabled persons and social assistance recipients) can obtain cash benefits provided by the provinces (Landespflegegeld). In 2015 the care allowance has been granted to 457,821 persons8. The merged levels 1 (23%) and 2 (29%) represent 51% of total beneficiaries: Level 1 2 3 4 5 6 7

Need of care (in hours) Over 65 hours Over 95 hours Over 120 hours Over 160 hours Over 180 hours and permanent need Over 180 hours and non-coordinable service Over 180 hours and permanent immobility

Amount € 154.20 € 284.3 € 442.90 € 664.30 € 902.30 €1260 € 1655.80

Beneficiaries 23% 29% 18% 14% 10% 4% 2%

Source: VIDA, 2015.

The care allowance is the key feature of the Austrian system, as it allows dependent persons to finance the freedom of choice for care. •

Respite care benefit is destined to the primary informal carers. It is provided on an annual tax-free basis. Depending on the level, the respite care benefit can reach EUR 1,200 (levels 1 to 3), EUR 1,400 (level 4), EUR 1,600 (level 5), EUR 2,000 (level 6) and EUR 2,200 (level 7).

•

24-hour care, available for persons that organise 24-hour care. The objective of this system is to provide assurance of nursing and care around the clock: the assistance is given to the person under care at the household and certain tasks relating to the personal care and eating. In addition to these tasks, under a doctor’s order a caregiver may perform certain defined medical tasks for example the administration of drugs, bandaging and subcutaneous injections. To benefit from this grant additionally to the cash benefit, the dependent person has to be recognised at least level 3. The amount of this grant depends on whom the dependent person has hired: an employee (EUR 1,100) or an independent worker (EUR 550).

The benefits in kind cover a variety of services which may be bought with the cash benefits. The beneficiary may also opt for them instead if more adapted for their care needs. Among them are: •

Mobile services: domiciliary care, home helpers, transitional care family assistance, 24hour care, meals on wheels, visiting service, and emergency hotlines

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Outreach services: therapeutic services and Länder advisory or counselling centres

•

Semi-institutional services: day centres

•

In-patient/institutional services: short-term care, transitional care, care during the vacations of the carer, nursing homes/residential homes/senior residences

•

Services for persons with disabilities: transport service, personal assistance, occupational therapy, and homes.

At last, there are the benefits for carers. They include paid and unpaid leave, working arrangements and pension credits, respite care, training and education. More recently, the importance of the informal care provision has led the Austrian authorities to set up another significant regulation: the 2007 Home Care Law, which recognises the predominance of informal care provision in Austria, and therefore aims at creating better regulation of informal care provision. Indeed, most persons in need of care in Austria (about 80%) prefer staying home and receiving informal care from relatives over formal care.

Home care social services The Art. 15a Agreement of 1993 requires all provinces to provide decentralised institutional, semiinstitutional and home-based services. For this purpose a catalogue of services and quality criteria for social services was included in the Agreement. The provinces are also responsible for interlinking the services offered and guaranteeing information and counselling.

The objectives of the system are the following: •

Persons in need of care should be able to choose freely among the services offered.

•

The expansion of home-based services has clear priority in relation to the expansion of institutionbased facilities.

•

Nursing homes should be small, decentralised and integrated into residential areas.

•

The expansion of new care services/facilities has to reduce the burden of caregiving for family members. The range of services provided is of crucial importance (e.g. day care, short-term care, respite care).

The Austrian LTC system distinguishes between two main types of social services: •

Institutional care services, which are mainly provided by the federal provinces and local authorities, or by religious and other non-profit organisations. These services usually include care in residential homes, nursing homes, day-care centres and night-care centres;

•

Home-care services, which are mainly provided by non-profit organisations, such as Caritas, Diakonie, Hilfswerk, Red Cross and Volkshilfe. They include, among others, home help, home nursing care, mobile therapeutic services, meals on wheels, transport services, home cleaning, laundry services and weekend help. Domestic care, practical help, such as cleaning and cooking,

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and help with instrumental activities of daily living can be included in care plans designed to provide a package of suitable home-care services. The provision of equipment, assistive devices and technology is included in such home-care packages. Home healthcare services Since 1992 the health care insurance covers home nursing (which is a health service that provides injections, nutrition via tubes, decubitus ulcer care, etc.), if the need is verified by a physician. Eligibility is dependent on illness and the provision is limited to four weeks. Among support measures for caregiving relatives, tthroughout Austria certified healthcare and nursing professionals visit the homes of all recipients of long-term care benefits to inform and counsel all those involved in the specific care situation in order to assure the quality of home care. The care vouchers e-pilot project (quality assurance in care at home) began in October 2004. Those entitled to receive the long-term care allowance can obtain information, advice and practical tips on the care system and different possibilities from a home visit by a specialist care professional (Leichsenring et al., 2009). In the first few years 63% of those who received this service reviewed the professional visit as “very good” and 35% said it was “good”. Around another 18 225 home visits were carried out in 2009. Education and training In principle, the job descriptions of health professionals (excluding physicians) as well as education and advanced training (voluntary and compulsory) are addressed in the Health and Nursing Law of 1997 (Gesundheits- und Krankenpflegegesetz, GuKG), which is overseen by the Federal Ministry of Health. Central to this law is the description of a separate area of activity for qualified nursing personnel. Three areas – namely those of exclusive responsibility, joint responsibility (together with a physician) and interdisciplinary responsibility (shared with other medical professionals) – are defined (§14, §15, §16 GuKG). This is intended to clarify the tasks and liabilities of qualified nursing personnel, which includes care assessment, diagnosis, planning, implementation and evaluation (in their area of exclusive responsibility). In reality, however, the separation of tasks and responsibilities is less clear and handled very differently. Also regulated in this law are the job descriptions and education of so-called ‘nursing aids’ (Pflegehelfer), who are certified to support nurses and doctors in their work. Regarding the education of care personnel (nurses and nursing aids), the Health and Nursing Law describes the necessary content of nurses’ theoretical education in a quite detailed manner. With respect to care services and their quality, such educational content as professional ethics, documentation and supervision, the care of older persons, home-based care and so forth is explicitly mentioned. Practical education comprises activity in hospitals, care institutions and institutions for other social or care services (e.g. homebased services). Nursing aids have a somewhat condensed version of the above-mentioned educational requirements (§92, §93 GuGK). Special education for leading and teaching care professionals is also regulated by this law (§65 GuGK).

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The required qualification for all professions in home care is regulated by the agreement on social professions established between the federal government and federal states (Art. 15a B-VG zwischen dem Bund und den Ländern über Sozialbetreuungsberufe, Wiener Landtag 2005). The same agreement regulates the job tasks of nurses, home care staff, and home aids. The Agreement on Social Care Professions (Vereinbarung über Sozialbetreuungsberufe) was signed by the federal government and the federal provinces pursuant to Article 15a of the federal constitution in 2005. It was a major step towards regulating professional profiles, occupational activities and training according to common targets and principles. The agreement provides for a modular system that facilitates the permeability of boundaries between the individual professions by increasing flexibility and mobility in the labour market. For example, the job profile ‘home helper’ has been introduced nationwide (before, it only existed in the federal provinces of Vienna, Lower Austria, Upper Austria and Styria, which have larger populations). The agreement anticipates an upgrading of the social care professions, and basic quality and education standards. People with a trade licence for providing personal assistance, working in private homes or working as self-employed nurses may attend free supplementary occupational training while working. According to the current programme of the Austrian federal government, the training system in the care sector shall be further developed. In this regard, it should reflect developments in the general educational system. Breaks in training should be gradually phased out in favour of continuous career training with defined interfaces, similar to the general educational system. Greater consideration of the demand for LTC should be given during training. Initiatives for qualification support for employees and for improving the situation of current employees in social and health homecare A) AMS employment campaign The Public Employment Service (Arbeitsmarktservice, AMS), which monitors provision and demand in various occupations has tackled the lack of personnel in the healthcare and social sector by an employment campaign. Qualification support for employees (Qualifizierungsförderung für Beschäftigte) is financed through this programme, which is being run within the framework of the European Social Fund. The minimum age for attending training in social and nursing professions is 17 years. Therefore, both the large social sector NGOs (such as Caritas and Diakonie) that are active in training and hospitals providing training in healthcare and the nursing professions offer voluntary job finding training or social work possibilities for up to one year to school-leavers (normally aged 15 years as compulsory education involves nine school years). In the framework of the upcoming structural reform of the health and care sector, up to 2014 a concise competency model for the sector and the different professions will be developed, starting from an analysis of the current situation and including representatives of all professions and some employers. The intention is to ensure a nationally uniform high-quality education with at least the school-leaving examination (which enables the student to attend university). Qualifications required for a certain profession will meet the practical requirements of the job and will allow for further training or career shifts within the sector (Reformarbeitsgruppe Pflege, 2012). B) BAGS initiative 562634-EPP-1-2015-IT-EPPKA2-SSA

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A collective bargaining agreement has been in place since 2004 for employees working in member companies of the umbrella organisation of employers in the health and social occupations (Berufsvereinigung von Arbeitgebern für Gesundheits- und Sozialberufe, BAGS). According to this union, some employers in the social and health sector have recently started to ask their employees about satisfaction with their work. The planned structural reform will help reduce fluctuation in the health and care sector by improving working conditions. Plans have been made to consider the different working conditions in stationary and mobile care and then optimise framework conditions, for example concerning working time, offering childcare facilities, organisation of work and duty rosters (Reformarbeitsgruppe Pflege, 2012). C) The Labour Foundation for Social Work and Healthcare Professionals

The Labour Foundation for Social Work and Healthcare Professionals is an initiative of the Vienna Employment Promotion Fund (Wiener ArbeitnehmerInnen Förderungsfonds, Waff) and the Public Employment Service (Arbeitsmarkservice, AMS). With this Labour Foundation, the Waff and AMS Vienna support Viennese health and care sector companies in their search for personnel. It provides unemployed people in Vienna with access to free vocational training in the care sector and a suitable employment option. Interested job-seekers get access to future-oriented occupations, such as home help, nursing assistance or certified nursing, with the objective of obtaining a full-time or part-time employment contract after completing vocational education. Companies receive support through tailor-made personnel recruitment and qualification measures as well as demand-oriented, close-to-job qualifications for future employees. Occupational qualifications provided within this Labour Foundation involve legally regulated theoretical and practical training, leading to the acquisition of a generally accepted qualification in the following professions: •

Social care professions: home help workers; social workers with a specific focus (working with older people and people with disabilities); diploma social workers with a specific focus (working with older people, families, people with disabilities).

•

Healthcare and nursing professions: certified health carers and nurses, and up to 2011, nursing assistants (are now trained within the framework of a different AMS support model).

C) University course for case and care management The federal province of Styria has, inter alia, introduced a university course for case and care management. In this advanced training programme, members of the higher grades of health and nursing services are trained to perform domiciliary nursing and care-giving tasks and to act as an interface between intramural and extramural care systems. Furthermore, advanced training courses for the higher grades of the health and nursing services and care assistants were developed, focusing on an “ageing society with increased nursing and care-giving requirements”.

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11.2 HHCP involved in older persons homecare service in Austria: roles and competences The HHCP mainly involved in the sector of mobile health and social care for older persons in Austria are: •

nurses, nurse assistants: this group belongs to the healthcare professions

•

home helpers , social care workers specialized in services for elderly persons and qualified social care workers specialized in services for elderly persons: this group belong to social care professions

Regulations on social care professions fall under the competence of the Laender. Related training programmes and professional profiles, however, were harmonised within the framework of an agreement on social care professions made in 2005 between the Federal Government and the Laender pursuant to Art. 15a of the Bundes-Verfassungsgesetz (Federal Constitutional Law). The legislative fundament of nurses and nurse assistants is the federal occupation law (Berufsgesetz) 108: Law for healthcare – GuKG 1997 (108. Bundesgesetz: Gesundheits- und Krankenpflegegesetz – GuKG 1997).

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HOME HELPER Home helpers support persons needing assistance in performing housekeeping tasks and activities of everyday life with a view to promoting own activities and helping them to help themselves. These activities also include assistance in basic care under the guidance and supervision of healthcare professionals. OCCUPATION

HOME HELPER

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive (involving the use of logical, intuitive and creative thinking) and practical (involving manual dexterity and the use of methods, materials, tools and instruments)

know how to be competence in terms of responsibility and autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc.

to know the hygiene measures

To clean and tidy in the direct surround of the client

To evaluate hygiene and safety risks in home environment

Performing housekeeping tasks

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to cook and prepare meals, e.g. heating frozen food, portioning and, if necessary, cutting food, preparing snacks, etc.

•

To evaluate compliance with dietary requirements

•

to give assistance with eating

•

to give assistance with drinking

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To evaluate the proper foods to be cooked and recognize of eating disorders, difficulties in swallowing, insufficient fluid intake and immediate information of the doctor or member of the professional level of the

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•

to ensure sufficient fluid intake

To support with shopping

To evaluate the proper foods to be bought on the basis of economic availability and food needs

To know documentation

To support older adults in administrative practices and dealing with authorities

To build a network around the old person

To support in social relations

To address the older adults to the main existing services which can improve his/her quality of life

To give motivation and support in self help

•

to provide assistance with getting up from bed

•

to provide assistance with washing

•

to provide assistance with taking a shower

•

to provide assistance with taking a bath

•

to provide assistance with dental care

To recognize changes in the general health status or skin and immediate information of the doctor or member of the professional level of the care service in charge style

•

to provide assistance with hair care

•

to provide assistance with shaving

•

to provide assistance with selecting clothing

•

to provide assistance with putting on and taking off garments,

To know the basics of domestic economy Supporting in activities of everyday life

Assistance in basic care

care service in charge

To know the basics of personal hygiene

To provide assistance with dressing and

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undressing

stockings, tights, socks, etc. and compression stockings

To provide support related to excretions

•

to provide assistance with toileting

•

to provide assistance with intimate hygiene after toileting

•

to provide assistance with incontinence products, e.g. changing protective pants and assisting with pads

•

to provide assistance with getting up or lying down

•

to provide assistance with sitting down

•

to provide assistance with walking

To provide support with positioning

•

to use of aids to prevent decubitus in wheelchair users

To provide support with taking and applying medicinal products

•

to provide assistance with oral medication, which also includes reminding the client to take medicines or taking medicines out of a one-week dispenser

•

to provide assistance with the application of prescribed ointments, creams and lotions, etc., or of skin care products ordered by members of the professional level of the care service.

To support and promote mobility

• to use of aids to facilitate daily activities for people suffering from rheumatic changes

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To observe persons condition

To observe persons condition

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SOCIAL CARE WORKERS SPECIALISED IN SERVICES FOR ELDERLY PERSONS Social care workers are skilled professionals helping to shape the living conditions of people who are disadvantaged in the way they lead their lives because of their age, disability or other difficult circumstances. They have comprehensive knowledge of the diverse aspects of living with disadvantages and can provide a broad range of counselling, support and assistance services related to all issues of life from coping with everyday life to finding a meaning to life. They provide tasks of assistant nursing: assistant nursing education and training forms an integral part of education for this profession. OCCUPATION

SOCIAL CARE WORKERS SPECIALISED IN SERVICES FOR ELDERLY PERSONS

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive (involving the use of logical, intuitive and creative thinking) and practical (involving manual dexterity and the use of methods, materials, tools and instruments)

know how to be competence in terms of responsibility and autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc.

To provide support, assistance and services related with daily life

To have a comprehensive knowledge of the diverse aspects of living with disadvantages:

• • •

to aid to restore, maintain and promote skill for an possible independent life in old age to adopt measures to increase quality of life of older persons to address physical, psychological, social and spiritual needs and resources

To contribute to increase and / or maintain quality of life of older persons

To know documentation

To support older adults in administrative practices and dealing with authorities

To build a network around the old person

To support in social

To address the older adults to the main existing services which can improve

To give motivation

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relations

and support in self help

his/her quality of life

To perform nursing measures ordered and supervised by qualified nurses

Providing tasks of assistant nursing To cooperate in therapeutic and diagnostic tasks ordered in writing by a doctor of medicine and supervised by qualified nurses or doctors of medicine:

•

To apply basic nursing techniques;

•

To apply basic mobilisation techniques;

•

To apply personal hygiene and nutrition measures;

•

To make patient observation;

•

To apply measures of preventive care;

•

To know documentation of nursing measures taken;

•

To clean and disinfection tools

•

To administer medicines;

•

To apply bandages and dressings;

•

To administer subcutaneous injections of insulin and anticoagulants, including taking blood from capillaries for measuring the blood sugar level by means of test strips;

•

To feed tube through an existing gastric tube;

•

To provide patient observation tasks required for medical reasons, e.g. measuring blood pressure, pulse rate, temperature, weight and excrements, and monitoring the patient’s consciousness level and breathing; simple measures of thermotherapy and light

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To provide knowledge and apply methods to maintain one’s own health potential

To provide knowledge and apply methods to maintain one’s own health potential

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therapy,

QUALIFIED SOCIAL CARE WORKERS SPECIALISED IN SERVICES FOR ELDERLY PERSONS Qualified social care workers perform all the activities that are also carried out by social care workers. Owing to their advanced, scientifically based education and the competences acquired during the preparation of their diploma thesis, they are able to fulfil their tasks with a higher level of autonomy and own responsibility. In addition to direct care work, qualified social care workers perform conceptual and planning tasks related to the organisation of care work. They provide tasks of assistant nursing: assistant nursing education and training forms an integral part of education for this profession. OCCUPATION

QUALIFIED SOCIAL CARE WORKERS SPECIALISED IN SERVICES FOR ELDERLY PERSONS

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive (involving the use of logical, intuitive and creative thinking) and practical (involving manual dexterity and the use of methods, materials, tools and instruments)

know how to be competence in terms of responsibility and autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc.

Planning and designing the care work

To develop on the basis of scientific knowledge concepts and projects, to perform independently and evaluate them.

•

Age-appropriate transformation of the living environment. Consulting and procurement of appropriate aids and remedies as well as organization of the necessary government agencies or insurance way.

•

Special entertainment programs for small groups and individuals to promote motor skills through movement exercises.

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Improve the social climate among the inhabitants and to the caregivers.

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To provide support, assistance and services related with daily life

Providing tasks of assistant nursing

To have a comprehensive knowledge of the diverse aspects of living with disadvantages:

•

Special entertainment programs to promote brain performance.

•

Developing strategies in the event of acute crisis situations, such as at death of relatives or roommates, depression and suicidal behavior, confusion and disorientation.

• • •

To aid to restore, maintain and promote skill for an possible independent life in old age to adopt measures to increase quality of life of older persons to address physical, psychological, social and spiritual needs and resources

To contribute to increase and / or maintain quality of life of older persons

To know documentation

To support older adults in administrative practices and dealing with authorities

To build a network around the old person

To support in social relations

To address the older adults to the main existing services which can improve his/her quality of life

To give motivation and support in self help

To perform nursing measures ordered and supervised by qualified nurses

•

To apply basic nursing techniques;

•

To apply basic mobilisation techniques;

•

To apply personal hygiene and nutrition measures;

•

To makepatient observation;

•

To apply measures of preventive care;

•

To know documentation of nursing measures taken;

•

To clean and disinfection tools

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To cooperate in therapeutic and diagnostic tasks ordered in writing by a doctor of medicine and supervised by qualified nurses or doctors of medicine:

•

To administer medicines;

•

To apply bandages and dressings;

•

To administer subcutaneous injections of insulin and anticoagulants, including taking blood from capillaries for measuring the blood sugar level by means of test strips;

•

To feed tube through an existing gastric tube;

•

To provide patient observation tasks required for medical reasons, e.g. measuring blood pressure, pulse rate, temperature, weight and excrements, and monitoring the patient’s consciousness level and breathing; simple measures of thermotherapy and light therapy,

To provide knowledge and apply methods to maintain one’s own health potential

NURSE ASSITANTS According to GuKG 1997 § 84 (see section “regulation”) the services of care assistants compass: • • •

the accomplishment of care measures the assistance with (health) care measures including the social support of patients and clients and the accomplishment of housekeeping activities. the accomplishment of (health) care measures may only be done under instruction and observation of members of the higher civil service for healthcare. Off-site instructions are to be given in written form.

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OCCUPATION

NURSE ASSISTANT

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive (involving the use of logical, intuitive and creative thinking) and practical (involving manual dexterity and the use of methods, materials, tools and instruments)

know how to be competence in terms of responsibility and autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc.

To perform nursing measures ordered and supervised by nurses

Co-operation in therapeutic and diagnostic tasks ordered in writing by a doctor and

To accomplish of (health) care measures

To accomplish of (health) care measures

•

to apply basic nursing techniques;

•

to apply basic mobilisation techniques;

•

to apply personal hygiene and nutrition measures;

•

to apply patient observation;

•

to apply measures of preventive care;

•

to do documentation of nursing measures taken;

•

to care, clean and disinfect tools

•

To administer medicines;

•

To apply bandages and dressings;

•

To administer subcutaneous injections of insulin and anticoagulants, including taking blood from capillaries for measuring

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To provide knowledge and apply methods to maintain one’s own health potential

To provide knowledge and apply methods to maintain one’s own health potential

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supervised by nurses or doctors

the blood sugar level by means of test strips; •

To feed tube through an existing gastric tube;

•

To provide patient observation tasks required for medical reasons, e.g. measuring blood pressure, pulse rate, temperature, weight and excrements, and monitoring the patient’s consciousness level and breathing; simple measures of thermotherapy and light therapy,

NURSES In Austria the activity of nursing and titles of the nurses are protected by law. By Paragraph 12 (1) of the law on nurses all those complying with the training required by the law6 (the general care nurse training) are entitled to use the title [Berufsbezeichnung] “Diplomierte Gesundheits- und Krankenschwester” / “Diplomierter Gesundheits- und Krankenpfleger” [qualified nurse]. For exercising their profession, qualified nurses in general care have acquired the following professional competence comprising expertise and methodological competence as well as instrumentation and technical competence. Based on the tasks of nursing care, the professional competence is structured into individualrelated, organisation-related and society-related competence.

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OCCUPATION

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive (involving the use of logical, intuitive and creative thinking) and practical (involving manual dexterity and the use of methods, materials, tools and instruments)

know how to be competence in terms of responsibility and autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc.

Activities managed on nurse’s own responsibility

Activities with shared responsibility

•

To know matters of diagnosis,

•

to plan, organize, implement and supervision all measures of care in the process of care

The physician bears responsibility for the issuing of orders, the nurse bears responsibility for implementing it. Doctor’s orders must be given in a written form; only in exceptional, medically

•

To apply procedures like anamnesis and diagnosis of care, implementation of measures of care and evaluation of care, but also documentation of the process of care.

To provide knowledge and apply methods to maintain one’s own health potential

•

To administer drugs,

•

To prepare of injections and to setting catheters

To provide knowledge and apply methods to maintain one’s own health potential

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justified cases can the order be issued orally. Matters under shared responsibility might well be of greater significance than those under the nurse’s own responsibility.

NURSE

Interdisciplinary activities are those that concern not solely areas of care but other areas of the health service. Interdisciplinary activities

To apply procedures like health counselling, advice and care during and after a physical or mental illness To prepare patients for the departure from the hospital and assistance if continued care is needed.

The nurse here will have the right of initiation and codecision and in turn, again, the responsibility for the implementation of the measures of care.

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11.2.1 References

•

BMASK, National Report on the Implementation of UNECE-RIS for MIPAA, 2007-2012, 2011

•

The European Observatory on Health Systems and Policies, Home care across Europe, Current structure and future challenges, 2012

•

Eurofound, More and better jobs in home-care services, European Foundation for the Improvement of Living and Working Conditions, 2013

•

VIDA (Gewerkschaft), www.vida.at

•

Quality of jobs and services in the Personal care and Household Services sector in Austria, European Project 4 Quality, 2015

•

European Centre for Social Welfare Policy and Research, From care in homes to care at home: European experiences with (de)institutionalisation in long-term care, 2015

•

Sozial Ministerium, National Social Reports Austria, 2014

•

Sozial Ministerium, Social Protection in Austria, 2014

•

Bundesministerium für Gesundheit, Healthcare professions in Austria, 2016

•

ENEPRI, Research report No. 69: The Long Term Care System for the elderly in Austria, 2010

•

ENEPRI, Research report No. 105: Quality assurance policies and indicators for long-term care in the European Union – Country report: Austria, 2012

•

Report of the Independent Expert on the enjoyment of all human rights by older persons, Rosa Kornfeld-Matte, Human Rights Council Thirtieth session – General Assembly of United Nations, 2015

•

European Observatory on Health Systems and Policies , Health system in transition (HiT) – Austria Health system review, 2013

•

The European Observatory on Health Systems and Policies, Public health in Austria, 2011

•

Caritas, Long term care in Austria – Home care Eurpe Conference, Vienna, 2009

•

Eurybase The Information Database on Education Systems in Europe, The Education System in Austria, 2008-2009

•

Vereinbarung gemäß Art. 15a B-VG zwischen dem Bund und den Ländern über Sozialbetreuungsberufe (Agreement on Social Care Professions made between the Federal Government and the Laender pursuant to Art. 15a of the Federal Constitutional Law), Federal Law Gazette I No. 55/2005

•

Gesundheits- und Krankenpflegegesetz (Nursing Act), Federal Law Gazette I No. 108/1997

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12 OLDER PERSONS HOMECARE IN BELGIUM Belgium, with a population of about 11 million inhabitants, faces demographic change in a strong manner. Between 2013 and 2060, the share of people aged 80+ will grow from 5.3% of the population to 8.9%, with most of this growth happening before 2045. The population 85+ will more than double, from 2.4% to 5.2%. Life expectancy for men and women at age 65 will rise from 17.4 and 20.9 years to 22.3 and 25.7 years.7

12.1Introduction to older persons homecare service in Belgium Belgium is a federal state, meaning that responsibility for health care generally and long-term care specifically is split between the regions, communities and the federal level8. The federal public health insurance, INAMI, covers many of the non-medical costs of long term care provision: help in the activities of daily living, both at home or in a care residence. Services financed through the public health insurance involves participating in the health care costs, this is also true for long-term care provisions. The amount that has to be paid personally is reduced for certain categories of persons, who are covered by a ‘maximum billable amount’. These concern both people with low income and with chronic health conditions. For older people, the federal level pays a ‘benefit for the support of older persons’ (‘allocation d’aide aux personnes âgées’ / ‘tegemoetkoming hup aan bejaarden’) that is allocated to persons over 65 with low or modest incomes and who show certain reductions in their activities of daily living. In Flanders, this help is topped up by a mandatory ‘long-term care insurance’, which can pay 130 euros to every person with severe or partial limitations in their capacity to be autonomous. In 2006, about 50% of long-term care patients were taken charge of in care institutions (public, private not-for-profit and private for-profit). Home care is provided in proportion to the restriction of activities of daily living and includes the provision of services which compensate for capacity loss, such via the provision of service vouchers. Service vouchers are subsidized partially by the federal government. Service vouchers also exist for the general population, allowing to receive tax reductions of about 2/3 of an hourly cost for the purchase of household services such as ironing or cooking – these vouchers are also used by older people with limitations, but as the system exists for the whole population, it is not known how much care is financed via this system. The exact offer of services varies between the regions. Semi-residential services for people who stay at home exist and consist in short-stay or day care centres. The number of home care users has grown by more than 20% between 2000 and 2011 7 8

SPC report on long term care https://www.oecd.org/fr/sante/systemes-sante/48432045.pdf

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Informal care stays important in the Belgian system: in 2006, about 9.4% of the population over 15 years of age was caring informally for another person, the majority being women aged between 45 and 60 years. Informal can reduce their working time (full-time or part-time leave) all while receiving a monthly benefit, and maintaining their coverage of social security rights. Every employee can also draw on 10 days of unpaid leave for ‘imperious reasons’ per year, for example in the case of the hospitalization of a person living in the same household.

12.2HHCP involved in older persons homecare service in Belgium: roles and competences According to the Social Protection Committee’s 2014 report on long-term care, nursing care is organised by the federal public health insurance system. Nurses need to be qualified and many are self-employed. In 2012, about 175.000 qualified nurses were registered, 4.200 of them with a special qualification in geriatric care. Nurses are helped by care professionals, who form structured teams with nurses. Non-medical services in home care are organised locally by staff employed by a public agency or private non-profit companies. The subsidized home care sector produced about 25 million care hours in 2006, equivalent to 17,000 full-time workers.9 In 2002, the Federal Government introduced the “Integrated Home Care Services” (‘Geïntegreerde Diensten Thuiszorg (GDT)’ / ’Service Intégré de Soins à Domicile (SISD)’), which are financed by the statutory health insurance system. This structure coordinates all medical disciplines involved in the care for patients for a specific geographical area. At the regional level, home care is coordinated by ‘Cooperation Initiatives Primary Care’ (‘SamenwerkingsInitiatieven Eerstelijnsgezondheidszorg’ or SELs) in Flanders and by the ‘Coordination Centres for Home Care and Services’ (‘Centres de Coordination de Soins et Services a Domicile’ or CSSDs) in Wallonia. Their main task is to guarantee the quality of care and the cooperation between staff involved in providing LTC to people in their own homes such GPs, home nurses, accredited services for home care and home help, aid for the elderly and social work, etc. In Flanders, a policy of coordination and cooperation between residential and home care services is implemented through the Act on Residential and Home Care (‘Woonzorgdecreet’, 2009). The legislative framework combines self-care, informal care and professional care in existing and new forms of home care; care that supports home care, and additional care and residential care.

9

SPC report on LTC

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12.2.1 Nursing auxiliary (‘aide soignant’) Nursing auxiliaries help nurses to provide hygienic care to patients: weighing, taking temperature, measuring heartbeat etc. Nursing auxiliaries have a legal status, an official vocational training pathway and can perform certain tasks that are generally performed by nurses, by delegation. ROLE (SET OF ACTIVITIES)

Monitoring: Observe and signal physical, psychological or social changes of the patient Hygiene and prevention

Assistance in activities of daily life

Assistance in the work of other health professionals

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge know how to do - SKILLS as cognitive

Observe the functioning of body sensors Observation of oral hydration Observation of the pulse and body temperature Dental hygiene Install and remove orthopaedic tights Hygienic care for stomas Application of measures to prevent bodily injuries Application of measures to prevent infections Application of measures in prevention of small injuries Help in nutrition and hydration Transport of patients Help in taking medicine Installation and observation of patients in a functional position with technical support Assistance of the patient in case of non-sterile taking of samples of secretions/excretions

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COMPETENCIES know how to be

Observation Medical skills Psychological skills

Emotional skills

Technical non-medical skills

Emotional skills

Skills in assistance, driving Psychological skills

Emotional skills

Technical medical skills

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Counselling

Assist the patient and his/her community in difficult moments

Psychological and emotional skills Knowledge of the health-care system

Emotional skills

Inform and advise the patient and his/her family according to the care plan on the authorized technical services

12.2.2 Nurses Nurses are qualified by a bachelor-degree academic training. All over Belgium, high schools (‘Haute Ecoles’/’Hoogeschools’) are training nurses alongside some universities. A difference is made in training between nurses generally and nurses in a hospital environment specifically, the latter ones requiring a higher qualification level. Nurses are employed by hospitals and can establish themselves as an independent profession, which intervene in the home environment as well. To be established as an independent nurse, nurses have to comply with the formalities linked to self-employment and, most importantly, receive a registration number from the Belgian federal health insurance (‘INAMI number’), which is limited in quantity. According to the European sector directive 2013/55/EU, nurses will have to have absolved 4600 hours of training, including 2300 hours minimum of professional practice with patients to be qualified, as well as to know 8 key competences identified in the Competence Framework of the European Federation of Nurses. The directive will enter into application in Belgium from September 2018. ROLE (SET OF ACTIVITIES)

Medical tasks

KNOWLEDGE

SKILLS

know what - theoretical and/or factual knowledge know how to do - SKILLS as cognitive

Comprehensive knowledge of the sciences on which general nursing is based, including sufficient understanding of the structure, physiological functions and behaviour of healthy and sick persons

Competence to independently initiate immediate measures to pre-serve life and to carry out measures in crisis and disaster situations

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COMPETENCIES know how to be

to plan, organize and implement nursing care when treating patients

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Knowledge of the nature and ethics of the profession and of the general principles of health and nursing Competence to independently diagnose the nursing care required using current theoretical and clinical knowledge as well as Playing in a team of health care professionals

Life-long learner

Competence to independently advise, instruct and support individuals needing care and their attachment figures Competence to independently ensure the quality of nursing care and assess it Clinical experience under the supervision of qualified nursing staff and in places where the number of qualified staff and equipment are appropriate for the nursing care of the patient Experience in working with health personnel and other professions in the health sector

Competence to analyze the quality of care in order to improve their own professional practice as general care nurses

Counselling of patients

Competence to work together effectively with other players in the health sector

Competence to communicate comprehensively and professionally and to cooperate with members of other professions in the health sector Ability to participate in practical training of health personnel

Competence to empower individuals, families and groups towards healthy lifestyles and selfcare

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12.2.3 Social Assistants Social assistants assess the situation of each patient and detect their needs, and participate in the planning of care and support the other professionals that go to provide home care. The minimum qualifications are to have completed a Bachelor’s degree in social assistance and to have a driver’s license ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

Organisation of help to the patients

Ability to detect needs of the patient

Preparation of a support plan

Systematised and structured working

Knowledge of the medical and social environment and available support services

Organisation of family support services, cleaning services etc.

Listening and availability for the patient and his/her family

Management of service providers

SKILLS know how to do - SKILLS as cognitive

COMPETENCIES know how to be

Evaluation of the patient’s situation and change of the support plan if necessary

Critical thinking

Management of the time planning of the team

Information management

Information management on new demands/needs Lead monthly team meetings

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Maintenance of relationships with professionals Human resources skills, communication skills

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12.2.4 Family helper (‘aide familiale’) Family helpers need to be in the possession of a certificate about their capacity to be a family helper, certifying the participation in a number of trainings on secondary-school level (‘auxiliaire familiale’). The ministry of health delivers certificates of registration as family helpers. Another requirement is a driver’s license. Together with patient’s guardians (‘garde malade’) and household support workers (‘aide ménagère’) and drivers, they provide the support in activities of daily living that go beyond medical tasks: cooking, housekeeping, helping the patient change positions, personal hygiene, mobility etc. Some of these tasks are provided under the service voucher system, others are part of personalized care plans. ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

Help in daily activities

Hygiene and medical tasks

Social and relational tasks

Monitoring

SKILLS know how to do - SKILLS as cognitive

Preparing meals Shopping Housekeeping Personal hygiene tasks Help in movements (change in positions) Help in administrative matters Organize the patient’s budget Orientation towards specialized services Look for signs of maltreatment or elder abuse Monitor the health status of the patient

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COMPETENCIES know how to be

Communicate and inform on hygiene and ergonomic adaptations of the household Listening to the patient Supporting the patient Counselling in difficult situations Competence in observation

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12.3 Sources: Organisation for Economic Cooperation and Development. H’elp wanted? Providing and Paying for Long-Term Care. Key findings and lessons learnt: Belgium’ In: OECD Healthy Policy Studies, 18 May 2011, , https://www.oecd.org/els/health-systems/47877421.pdf (consulted on 20 May 2016). European Union, Adequate social protection for long-term care needs in an ageing society. Report jointly prepared by the Social Protection Committee and the European Commission, 2014, http://ec.europa.eu/social/BlobServlet?docId=12808&langId=en (consulted on 20 May 2016). Aide-soignant.be, Liste des activités que l’aide-soignant peut effectuer sous le contrôle de l’infirmier/iere et dans une equipe structurée, http://www.aide-soignant.be/wpcontent/uploads/2014/01/residentialcare101.pdf (consulted on 25 May 2016). European Federation of Nurses, EFN Competency Framework for Mutual Recognition of Professional Qualifications Directive 2005/36/EC, amended by Directive 2013/55/EU, http://www.efnweb.be/?page_id=6897 (consulted on 25 May 2016). Centrale des services à domicile et services associées, Assistant social, http://www.fcsd.be/ToutUnMetier/IntegrerNotreEquipe/DecouvrezNosMetiers/Pages/assistantsocial.aspx (consulted on 25 May 2016). Centrale des services à domicile et services associées, Aide familiale, http://www.fcsd.be/ToutUnMetier/IntegrerNotreEquipe/DecouvrezNosMetiers/Pages/aidefamiliale.aspx (consulted on 25 May 2016).

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13 OLDER PERSONS HOMECARE IN BULGARIA

13.1Introduction to older persons homecare service in Bulgaria In Bulgaria, according to the statistics, life expectancy at birth reached 74.33 years in 201410. The life expectancy of those over 65 is 14.8 years, which is the lowest in the EU and the disability adjusted life years are comparatively low (WHO/HFA,23-03-2010). The low population density and the negative population growth rate are poor circumstances for service development and informal care. Despite a period of rapid economic growth after accession in 2007, Bulgaria is still the poorest country in the EU (Genet et al. 2013). Citizens as well as medical professionals are dissatisfied with the health care system; equity is a challenge not only because of differences in health needs, but also because of socioeconomic disparities and territorial imbalances. The insufficiency of the services at the moment finds expression in the inadequate coverage by the operative organizations and programs. There are areas in the country where patients do not have access to such a service (Yanakieva et al., 2014). The decrease of medical care personnel (shortage of medical nurses, physicians, rehabilitation specialists etc.), particularly in small towns and remote populated areas restricts the access to medical help and quality healthcare services to patients in those areas. According the researches made amongst the medical professionals as well as bed-ridden patients in, the majority of the population would not take advantage of homecare unless it is being financed by an institution or family and close relatives due to the impossibility to allocate enough money from the personal budget. This is the reason why the provision of Medical Home Care should be a priority in developing the relevant legislation (Yanakieva et al., 2014) Healthcare is mainly privately provided, while public providers and NGOs provide social services. Most of the healthcare services are provided by medical institutions, having contracts with the National Health Insurance Agency. It not envisaged that NGOs delivers health care services, but this causes often problems of coordination since very often the clients need and integrated social-medical service. In Bulgaria the governmental policy on home care is weak and no policy paper has exclusively addressed homecare. Within Bulgarian cultural tradition, it is considered the duty of families to take care of their elderly relatives even though this is not a legal obligation. Anyway, the situation of care dependent elderly people furthermore suffers from the decreasing availability of informal care, which not just results from demographic developments but also from large scale emigration of younger people. Usually, healthcare services and social services are separately provided. Hospitals, homes for the elderly and hospices are not involved in homecare. By lack of public financial resources social and health care services often require private payments. But Bulgarian elderly persons are the poorest in Europe and for many of them this is an obstacle to access to services they need (Genet et al. 2013). 10

http://www.indexmundi.com/bulgaria/life_expectancy_at_birth.html

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13.1.1 Home healthcare in Bulgaria Home health care is not well developed in Bulgaria; it is managed under the Ministry of Health and provided by GPs and practice nurses. Although making home visit is an official task of GPs and their practice nurses, covered by the basic health insurance, such home visits are sparsely made due to the lack of time and are anyway not enough to meet all needs. Home nursing is unknown in most parts of the country. In fact, formal home nursing services are delivered on a very limited scale by GP nurses and by nurses employed by NGOs. Nurses exclusively working in organized home care services are very scarce , while hospital nurses may provide privately paid home nursing care as a sideline job to those who can afford. GPs decide whether nursing homecare should be provided to the patient or not, but there are no uniform national eligibility criteria for this choice.

13.1.2 Social homecare in Bulgaria As organized nursing services at home are rare in Bulgaria, home care is often considered limited to social services. Provision of personal care and domestic aid is mainly public or private not-for-profit. The provision of social services activity is under the joint responsibility of the Ministry of Labour and Social Policy and the municipalities, which manage and organize the service at local level. To apply for personal care and domestic aid no doctors referral is required. Application for these services are usually submitted to the local Social Assistance Agency. Other Options for submissions are the municipalities and the NGOs. Personal care, domestic aid and technical aid are only available for people with a disability holding a nationally regulated certificate of being disabled (meaning to have lost the ability to work for at least 50%) (Panayotova 2009). Most home social services arrangements in Bulgaria are part of the following three schemes, each applying its own eligibility criteria (Genet et al. 2013). A. Home Social Patronage Home Social Patronage is a national scheme managed by municipalities aiming to provide basic care to frail populations, like elderly, poor and disabled people, including (Salonen & Kinos, 2012): -

provision of food, i.e. daily hot meals and a diet suitable for the elderly; maintenance of hygiene at home; assistance in supplying the necessary technical aids for the sick and disabled people for health monitoring, measurement of blood pressure, etc. assistance in purchasing food and basic necessities, pay bills, etc. assistance with applications in the “Social Assistance” (see point 2) directorate and other health institutions, disability or serious illness;

The social patronage is a type of community based social service financed from the municipal budget (with municipal financial means). It is possible for the municipality to directly provide this type of service by establishing a municipal organization for this purpose or to contract out the delivery of the service to a private provider. 562634-EPP-1-2015-IT-EPPKA2-SSA

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To get this service people needs to be disabled, over 65 years old, unable to organize ones living needs, without close relatives taking care and not own a home. Very often municipalities deliver directly home social patronage service, but sometimes they contract out or outsource to private providers, mainly NGOs (Genet et al. 2013). Social Patronage services are provided by professional workers, such as social workers, domestic aids and rehabilitators. B. Social Assistance The Social Assistance Agency developed a national program called the “Social assistant”, which is the only operative national program covering the social aspect of the Medical Home Care (Salonen & Kinos, 2012). The Social Assistance scheme enables the provision of personal care and support and domestic aid to gravely ill persons and to disabled people by Personal Assistants. The inclusion into the program of patients is open only to persons not using social services such as Personal Assistant or Social Assistant delivered by other organizations, companies or donor’s programs. Personal assistants are informal carers receiving financial support from the Social Assistance program, run by municipalities. This program provide employment for unemployed persons to alleviate the situation of families in which a disabled person is in need of constant care. The Social Assistant create the conditions for the social inclusion of people with disabilities, providing a qualified assistance to them and their families by supporting the maintenance and development of strengths and positive characteristics in the value system of the person and by promoting self-reliance (Salonen & Kinos, 2012). To become “Social Assistants to persons with disabilities” unemployed people are trained for only a couple of days for assistance work. C. Social Services in the Home Environment The recently established national programme “Social Services in the Home Environment” is locally managed by the municipalities and is focused on social activation and on light household support (for instance, administration). One of the goals of the program is to ensure additional training and employment of persons who already have experience as social assistants or people helping in clients’ household. Each Home Helper serves several clients. The Home Helpers spend equal time in each client’s household, regardless the differences in clients’ needs (Genet et al. 2013). In general, it is not possible to combine the use of Services from different schemes. In addition to national schemes, municipalities may develop their own additional social assistance programmes. There are no special rehabilitation programmes funded by the government, though most new community services – day-care centres, protected housing, rehabilitation centres – include rehabilitation programmes and focus on physical aspects of “recovery”

13.1.3 The role of NGOs and Bulgarian Red Cross The NGOs play a key role in the realization of the democratic participation principles. A major characteristic of those organizations is their independence from the State and other social sectors. Beside the independence, the NGOs hold a varied and precious experience in areas providing reliable and stable development of society (Genet et al. 2013). 562634-EPP-1-2015-IT-EPPKA2-SSA

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In Bulgaria, an important role is played by the Bulgarian Red Cross (http://en.redcross.bg). It implements an integrated model of complex provision of health and social cares at the homes of older people and people with disabilities. This model is based on the experience of the Swiss association "Spitex" and has successfully been adapted to Bulgarian conditions. The center for home care analyses and evaluates the needs of patients ,organizes staff training, provides the services and monitors their quality. The staff of the Home Care centers consists of nurses and home-helpers trained in the specific aspects of care provision in home environment. The nurses provide some primary health cares - taking blood pressure, control of heart activity, bandages, while the services provided by the home-helpers include: maintenance of personal and home hygiene, shopping, feeding, paying bills, support in administrative procedures, etc. An important aspect of the activities of the Home Care centers is the support of the patients’ capacity for selfhelp as well as the training of their family members in how to provide the cares needed. In addition, the BRC has also developed teams of volunteers at each Home Care Center, who support actively the provision of services at the homes of the beneficiaries after going through a special training. The Bulgarian Red Cross is the only organisation whose as they call them ‘home nurses’ and ‘home helps’ (personal care and domestic aid) have followed additional training specifically on home care (supported by the Swiss Red Cross). A mandatory requirement for working at the Home Care centers is the training provided both to nurses and home-helpers prior to their appointment. The BRC is licensed at the National Agency for Professional Education and Training for the provision of a professional training in the following specialty “Social services for children and older people with chronic diseases, physical and sensor impairments” which has two modules: “Home-helpers and Hospital Attendants” and the second module – “Social Assistant”. The training is focused on the specific aspects of care provision in home environment. The training programs are elaborated with the support of the Swiss Red Cross, they are in conformity with the European requirements in this field and have been adapted to the conditions in Bulgaria. Trainers in the trainings are lecturers from the Medical University in Sofia and members of the Bulgarian Association of Professionals in Nursing Cares.

13.1.4 “Home Care and Assistance Services towards Independent and Dignified Life” Project The Bulgarian Red Cross is currently implementing, in the capacity of an Executing Agency (EA) in partnership with the Ministry of Health, Ministry of Labour and Social Policy and the Swiss Red Cross , the “Home Care and Assistance Services towards Independent and Dignified Life” Project (2012-2017). The goal of the project is to support the introduction in Bulgaria of a model for complex provision of health cares and social services at home as a form of long-term care for older people with chronic diseases and permanent disabilities drawing on the Swiss experience. Except for provision of home care services to beneficiaries in the target region and improving of their quality of life, the project aims at establishing an institutional framework for sustainable provision of this type of services in Bulgaria, incl. proper legislative regulation, payment mechanisms, national quality standards and unified training programs for the staff. Among the main priorities of the project is to raise the awareness on home care services at all levels of the Bulgarian society in order to validate them as a form of integrated provision of health and social services to older people with chronic diseases and disabilities. One of the main results of the project was achieved in September 2015 when the legal changes elaborated by the Bulgarian Red Cross jointly with the Ministry of Health and Ministry of Labour and Social Policy were adopted by the Parliament. The texts approved in the Health Act regulated for the first time in Bulgaria the integrated provision of health and social services for various target groups at home, among them older people with chronic diseases and disabilities, pregnant women and children. The next step will be the establishment 562634-EPP-1-2015-IT-EPPKA2-SSA

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of an expert group with regard to the elaboration of the sub-legislative regulation. According to the texts adopted in the Health Act, the organization, provision, control of home care services, training requirements, criteria for selection of beneficiaries, etc. should be regulated by a joint order of the MH and MLSP in 2016 (Bulgarian Red Cross website http://en.redcross.bg )

13.2 HHCP involved in older persons homecare service in Bulgaria: roles and competences NURSES The lack of reports describing activities and responsibilities of nurses doesn’t permit to define in detail the roles and competences of nurses homecare in Bulgaria and this is one of the issues raised from Home care across Europe case study on Bulgaria (2011) that has been pointed out as obstacle to allow nurses work independently. Based on available information, nurse in homecare perform health education, administrative tasks supporting GP and health assistance, including injection and wound treatment. They are involved in different work setting including public services in collaboration with GP, despite very limited, NGOs, social services delivered by municipalities and privately. Nursing study program in Bulgaria is a full-time four-year nursing course leading to a Bachelor of Science in nursing. There are no specific regulation for the homecare services certification. Nurses have to take training courses and other accredited forms of continuous training annually organized by BAPZG (Bulgarian Association of Health Care Processionals) and Medical University-Sofia /Post graduated training department. As an upper margin, the education for nurses encompasses at least 4.600 hours of education and a minimum amount of 180 ECTS. Participation in the Bologna Process aims to make academic degree standards and quality assurance standards comparable. In Bulgaria, the main providers of nursing education at initial level are medical colleges. The training is held according to the modern curriculum and syllabus which answer the European and world standards. After Bulgaria signed the Bologna Declaration [1999], the three-tiered higher education model (Bachelor’s, Master’s, and Doctoral degrees) was introduced on account of the amendments and additions put forward in the new Higher Education Act [Popova et al., 2011]. Since 2007 nursing study program in Bulgaria is a full-time fouryear nursing course leading to a Bachelor of Science in nursing. Once obtained this degree a nurse can provide homecare: no specific training is envisaged for homecare nurses (IENE Project website http://www.ieneproject.eu/ ). No specific information about Bulgarian nurses competences have been retrieved.

HEALTHCARE ASSISTANT11 The regulation of competences of nurses, midwifes and other associated medical specialists and health assistants was accepted on February 8th 201112. This regulation describes the professional activities 11

Source: EU-Project: Creating a pilot network of nurse educators and regulators (SANCO/1/2009) - Country Profile Bulgaria - Health Assistanthttp://www.hca-network.eu/downloads/Country%20Profile%20Bulgaria%20131004.pdf 12 Ordinance No 1 of 8th February 2011 for occupational activities that nurses, midwives, associated medical specialists and medical assistants may operate as appointed or selforganized, issued by the Ministry of Health From 18th February 2011.

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that health assistants are supposed to perform on doctors’ or nurses’ order or without supervision. State educational requirements for acquiring qualification in the profession of "Healthcare Assistant", specifies requirements for the acquisition of third-level qualification for the specialty "Health care". Until now there is no compulsory examination for the target group. In future the Ministry of Education will plan a project to make their education compulsory, and in that course there will be compulsory and structured examination. Health assistants service the patients by assisting them in feeding, toileting, transporting and providing comfort and good hygiene in the patients’ room. Services to patients through assistance, including: nutrition; a common toilet; transportation and support for examinations; normal daily activities; providing comfort and hygiene in the hospital environment. Professional activities that health assistants may perform in sterilizing units are preparing material for surgery and other material for sterilization in accordance with the approved working rules for chemical and microbiological control of the sterilization process.

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ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

SKILLS know how to do - SKILLS as cognitive

COMPETENCIES know how to be

Observe the rules for health and safety and protect the environment in performance of their duties Applicable regulations (Health Law, Medical Establishments Act, Ordinance No 1 of 08.02.2011, the Ministry of Health) in the provision of basic health care Effectively communicate with patients Common to the profession "Healthcare Assistant"

Effectively communicate the work team quality standards

Provide care in accordance with the quality standards Respond appropriately in stressful situations Show a willingness to upgrade their professional competence and develop their personal qualities

Competencies on the physiology and pathophysiology of the human

Knowing the physiology and pathophysiology of the human anatomy (by system) Named symptoms of the most common acute surgical conditions

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Knowing the symptoms of orthopedic and traumatic conditions Knowing the most common diseases of the internal organs Performing in health care for specific diseases of internal organs Knowing physiological conditions of the child and the pathological changes in different diseases Performing activities related to the child's physiological state and pathological changes in disease Making self-care infectious and cancer Performing activities where necessary to provide emergency medical care Collecting, recording and processing data Competencies related to general patient care

Knowing the structure and organization of medical work Knowing applicable regulations and standards for better health care Performing independently of the patient types toilet Complying with the provisions of the dietitian for medical nutrition patient

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Monitoring and recording the activity of the excretory system Competences on hygiene rules and standards in hospitals

Applying basic rules of asepsis and antisepsis

Performing disinfection of surfaces, objects and hospital linen Participating in activities of prevention of hospital-acquired infections (nosocomial infection) Knowledge on social and legal relationship of the health assistant

SOCIAL ASSISTANT Social assistant is a person providing a set of services focused on social work and counselling to the clients and such needs as leisure time organisation and social contacts (Mincheva & Kanazireva, 2010). Clients are: persons with permanently impaired working capacity to the extent of 90% and over, entitled to “assistance of other people”; children with 50% and over impaired social adaptation ability entitled to assistance by other people; severely ill single elderly people experiencing autonomy difficulties, certified by a Medical Expert Board Protocol; adults or children leaving specialised institutions for disability. The distinction between social, home and personal assistant has not been laid down (Toptchiyska & Vasileva 2009). All three professions are described as persons providing meals, domestic aid and monitoring of the health status in the home environment and providing information to the GP (Toptchiyska & Vasileva 2009).

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ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

to know the basics of domestic economy

SKILLS know how to do - SKILLS as cognitive

to go grocery shopping to cook meals

to know the basics of nutrition principles

COMPETENCIES know how to be

to evaluate the proper foods to be bought on the basis of economic availability and food needs

Social work to know the basics of personal hygiene to know the basics of hygiene in home environment (cleaning, food etc.)

Administrative support Liaison with GPs Social participation

to know the basics about the administrative practices related to aging/disability management

to provide personal hygiene to clean home environment

to support older adults in compiling fiscal practices and other administrative practices to help with taking medicines To organize time of clients To foster clients social participation

PERSONAL ASSISTANT According to the legal definition this is a person providing permanent care to a child or elderly person with some kind of a permanent disability or to an elderly person with a permanent disability, or to a severely ill person for the purpose of meeting that person’s everyday needs. Personal assistants are usually persons of working age and co-habitant family member of recipient. No specific education or training is needed. The distinction between social, home and personal assistant has not been laid down (Toptchiyska & Vasileva 2009). All three professions are described as persons providing meals, domestic aid and monitoring of the health status in the home environment and providing information to the GP (Toptchiyska & Vasileva 2009). 562634-EPP-1-2015-IT-EPPKA2-SSA

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ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

know how to be

to go grocery shopping to cook meals

Social work

to provide personal hygiene and personal care in general to clean home environment

Administrative support

to know the basics about the administrative practices related to aging/disability management (e.g. Rules for the Implementation of the Social Assistance Act)

to support older adults in compiling fiscal practices and other administrative practices to help the client with eating

Daily living facilitation

To help the client with moving around

HOME HELPER The “Home Helper Service” has been introduced since the beginning of 2009 as part of the National Programme “Social Services in a Family Environment”. Home Helpers are normally working for NGOs. The Bulgarian Red Cross (BRC), through the National Training Center, provides trainings for them. The home helper is a person who provides services at home, focused on the maintenance of hygiene in the home, shopping and cooking, washing and other everyday activities. These services are intended for people with different kinds of disability (regardless of age) whose health constraints lead to their isolation and/or inability to look after themselves and organize the everyday activities. ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive and practical

know how to be

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to know the basics of domestic economy to know the basics of nutrition principles Social work

to know the basics of personal hygiene to know the basics of hygiene in home environment (cleaning, food etc.)

to buy food, medicines and vital items with money provided by the recipient of the services to cook meals

to evaluate the proper foods to be bought on the basis of economic availability and food needs

to provide personal hygiene to clean home environment

to carry out small repairs at home and/or to provide assistance in their execution Administrative support

to support older adults in paying bills and taxes

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13.2.1 References Bulgarian Red Cross website http://en.redcross.bg EC, 2013, Mapping and analysing bottleneck ec.europa.eu/social/BlobServlet?docId=12645&langId=en

vacancies

on

EU

Labour

Markets

Genet, N., Boerma, W., Kroneman, M., Hutchinson, A., & Saltman, R.B. (2013). Home care across Europe. Copenhagen: WHO, Regional Office for Europe (on behalf of the European Observatory on Health Systems and Policies) http://www.nivel.nl/sites/default/files/bestanden/Home-care-acrossEurope-case-studies.pdf Mincheva L. & Kanazireva G., The System of Long-Term Care in Bulgaria (May 28, 2010). ENEPRI Research http://ssrn.com/abstract=2033694 or Report No. 71. Available at SSRN: http://dx.doi.org/10.2139/ssrn.2033694

Salonen, K. & Kinos, S., Good practices and visions of the future of home care work in Bulgaria, Finland, Greece and Turkey. EQUIP II (2010-2012). 2012. Turku Education Department & Turku Vocational Institute. Toptchiyska, D. & Vasileva, E. 2009, Report on transferability in Bulgaria of the model for the validation of competences acquired as a result of professional experience for occupations in the social sector, developed in Italy within the project “Care Talents”, Balkanplan Ltd, Bulgaria. Yanakieva, A. Y.; Vodenitcharova, Y. Y.; Bancheva, M. A. (2014): Need of the Service Medical Home Care and Perspectives for Public-Private Partnership in Bulgaria. In: Planet@Risk, 2(4), Special Issue on One Health: 298-302, Davos: Global Risk Forum GRF Davos.

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14 OLDER PERSONS HOMECARE IN CROATIA 14.1 Introduction to older persons homecare service in Croatia Similar to other European countries, Croatia is bearing how their elderly are growing in population. In 2016 the number of people living in the Republic of Croatia reached 4,254,008. Life expectancy is currently at 75.8 years (above average of global expectation which, according to Population Division of the Department of Economic and Social Affairs of the United Nations, is at 71 years old). And the ratio births/deaths has been coming across a constant decrease of 0.08 % for the past 4 years. This means 16.9% population is over the age of 65. Thus, age dependency ratio in Croatia reaches now 24.8% (data from U.N. Statistics Division). By 2031 the share of older people was estimated in a range from 21.8% to 25.4% (the later, in the worst of prospects). Professional home care has traditionally been under the scope of work of family doctors teams. From 1993 Home Care Nursing Service (HCNS) was introduced as separate health care institution under the supervision of patients´ personal doctor. Long-term care (LTC) in Croatia is mainly organized within the social welfare system. Most of it is financed from the State budget (96%), while the remainder comes from out of pocket payments of the beneficiaries and from local and regional self-governing units, and includes sanitary transportation and home care. The initial patient´s needs assessment, before the HCNS starts home care, is done by the personal family doctor and public health nurse. Frequency of nurse visits is also determined by the Croatian Health Insurance Institute (CHII) regulation, usually within a range of 2-5 times a week during several months. Physical therapy at home is also part of the NCHS, but for this service the recommendation from the specialist of physical medicine is required. The standard number of inhabitants per one nurse and per one physical therapist at home is set by CHII regulation, as well. The users are mainly elderly over the age of 70 and are mostly satisfied with the service, even though they do not have any possibility to freely choose the providers, institution and nurse. The Social Care Act (Croatian law for social care and health care issues in force since 1998) includes provisions on generational solidarity, which are to keep the elderly in their own homes and with their family; promote their social inclusion; and improve their quality of life by developing and expanding noninstitutional services and volunteering. Spouses still play an important role in the provision of informal personal care. In Croatia, spouses, especially wives, are the primary caregivers for the elderly, without any fees. Informal caregivers are not recognized in the expenditure system (in 2012 only 5.8 % of 65+ were covered by eldercare system). Nevertheless, there is still a large number of the elderly population who live alone and who are at risk of having unmet LTC needs. Informal care is also provided by friends and neighbors. Recipients of social assistance and welfare are divided into two basic categories: (1) those who earn no income or whose income is below a certain threshold; and (2) persons who receive assistance (financial and other). The quantity of health personnel (nurses, physiotherapists, etc.) of the NHNCS for this network is planned according to geographical distribution of inhabitants, geographical characteristics and local circumstances, with huge regional differences in their distributions. Large cities and cities which are the seats of counties are obliged to provide other types of material support and assistance, including the promotion of volunteering and the work of civil society organizations. There are 10 categories of social services (benefits 562634-EPP-1-2015-IT-EPPKA2-SSA

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in kind), regulated by the CHII including in-home assistance and home care and comprise the different types of medical treatment, delivery of meals, housework and assistance with personal hygiene. It is awarded to persons with secured housing but who are, due to old age, affected by disability or other grave health conditions, unable to take care of their personal needs alone or with the help of their family. The condition for receiving this social service is that the assistance cannot be obtained from their parents, spouse or children, nor based on life maintenance and support agreements or other regulations. A range of institutionalized forms of care, such as permanent or temporary accommodation, or even daily or shorter stays in care centers, is also available. There are various pensioners’ associations organized at national, regional and local levels. The continuing problem of LTC in Croatia is that it is dispersed between the health and social welfare systems, which has a negative impact on the accessibility, recognizability and adequacy of the provided services. At present, long-term care is still split between the health care system and the social welfare system. It is important to point out that the implementation of the Strategic Plan of Palliative Care Development in the Republic of Croatia 2014-2016 continues. The Ministry of Social Policy and Youth published three invitations to submit projects and programs in 2014 relating to various forms of care for the elderly, including the financing of three-year programs of civil society organizations for the provision of the service "Hello for Help" for the elderly, organizing daily activities for them in local communities, and the services of transport for the elderly to medical institutions and other relevant institutions, and the services of advising the elderly about the potential harmful effects of contracts of maintenance for life or contracts of maintenance until death. In 2014, the Ministry of Social Policy and Youth financed in total 78 projects and programs attempting to increase the quality of life of the elderly. Any health care professional with college degree and five years of experience is allowed to enter into the business, either publicly financed through a contract by the Croatian Health Insurance Found (CHIF) or paid by the user´s fees only. The vast majority of Croatian workers providing LTC in institutionalized settings or privately employed by families, are women. Regarding professional educational framework the Croatian model of Education complies with university study programs and qualification standards designed according to recommendations, directives and regulations of the European Union and the World Health Organization, adjusted to specific requirements of the educational process in the Republic of Croatia. Croatian Qualifications Framework (CROQF) was referenced to European Qualifications Framework (EQF) in 2014 and meet with Bologna process. •

The Ministry of Science, Education and Sports is the main governing body in Croatia. (Public university study programs are self-accredited by the university senates).

•

The National Council for Higher Education is an advisory body of the Croatian Parliament who manages the development and quality of higher education.

•

The Agency for Science and Higher Education (ASHE), an independent public authority, is the accrediting authority of programs offered by the private higher education institutions, school of professional higher education and polytechnics.

Basic nursing education is attained at the secondary school level. The program includes subjects such as Croatian language, geography, history and arithmetic, with just a few hours per week of medical sciences and clinical practice. Nurses qualify from these programs at the age of 18 and receive a license to

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practice. There is a wide variety of courses (two, three and four-year programs). Studying is possible on a full-time basis, as “evening school” in addition to regular work and even “week-end” courses. According to the Croatian university practice and the Law on professional Titles and Academic Degrees any health study program should continue on three levels, following the scheme 180+120+180 European Credit Transfer and Accumulation System (ECTS).: •

Undergraduate Study (Bachelor Degree) for Nursing, Physiotherapy, Midwifery, Radiologic Technology and Medical Laboratory Diagnostics. To enroll in this program applicants are required to meet the academic entrance requirements which include the completion of four-year secondary education (Level 4 or higher) and the result of the State Graduation Test (Matura Exam).

•

University Graduate Study (Master Degree) for Nursing, Physiotherapy and Radiologic Technology

•

University Postgraduate Study (Doctoral Degree) Research, following related professions, participation in nursing education, etc.

As for non-formal and informal learning the CROQF validates by an ordinance a link to NQF mainly for adult and higher education as a craftsperson. Complying with EQVET equivalences, Level 2 would allow a Vocational Training Certificate; Level 4.2 Upper secondary general education school leaving certificate; or Master craftsman Diploma; Level 5 Professional Higher Education Diploma, and so on. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971660/

14.2HHCP involved in older persons homecare service in Croatia: roles and competences

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OCCUPATION - HCCP

ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

SKILLS know how to do - SKILLS as cognitive

To know basics on how to do housework.

To keep hygienic conditions of the customer´s personal environment.

To use cleaning products in a proper way

To do daily housework

To have a positive attitude if the elderly person is untidy

To know basics of hygiene in home environment (cleaning, food etc.)

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To know basics on how to deliver meal services

To follow instructions on how to deliver meals correctly

To be able to care for meal services maintenance

To know how meal delivery services should proceed

To take action when meal service delivery is incorrect

To solve minor disorders when meal service delivery is unfit

To know basics physical and mental health conditions

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

Environmental monitoring

HHCP1 Non-Formal / Informal Careers (EQF Level 0 to 2)

Health monitoring

To take action to reduce the risks To know basic ways of communicating risk conditions

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COMPETENCIES know how to be

To be patient with mentally or physically disabled To communicate correctly those health risks to the elderly person and/or other personnel involved

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To have basic ideas about domestic economy

Activities of daily living support

Values and principals

HHCP2 Adult Education (EQF Level 0 to 2)

To do shopping

To be motived to give advices about food to buy on the basis of economic availability and food needs

To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment)

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To have a basic knowledge of socialization process

To promote socialization

Ability to evaluate and assess a socialization process

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations

To reinforce equality, diversity and transcultural approaches

To know basics of nutrition

To have basic knowledge of disrespectful or inappropriate circumstances

To know basics on how to do housework. Environmental monitoring

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To use cleaning products in a proper way

To do daily housework

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To know basics of hygiene in home environment (cleaning, food etc.)

To know basics physical and mental health conditions

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

To take action to reduce the risks Health monitoring To know basic ways of communicating risk conditions

To report any health risk (to whom, how and when)

To have basic ideas about domestic economy

To be patient with mentally or physically disabled To communicate correctly those health risks to the elderly person and/or other personnel involved

To do shopping

To be motived to give advices about food to buy on the basis of economic availability and food needs

To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment)

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To have a basic knowledge of socialization process

To promote socialization

Ability to evaluate and assess a socialization process

To know basics of nutrition Activities of daily living support

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Values and principals

To have basic knowledge of disrespectful or inappropriate circumstances

To know basics on how to do housework.

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations

To reinforce equality, diversity and transcultural approaches

To keep hygienic conditions of the customer´s personal environment.

To use cleaning products in a proper way

To do daily housework

To have a positive attitude if the elderly person is untidy

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

Environmental monitoring To know basics of hygiene in home environment (cleaning, food etc.)

HHCP3 Volunteers (EQF Level 0 to 2)

To know basics physical and mental health conditions

To take action to reduce the risks Health monitoring To know basic ways of communicating risk conditions

Activities of daily living support

To have basic ideas about domestic economy

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To report any health risk (to whom, how and when)

To do grocery shopping

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To know basics of nutrition

Values and principals

HHCP4 Physiotherapy technician/masseurs (EQF Level 0 to 2) HHCP5 Nursing Bachelor´s Degree (Level 4.2)

Activities for physiotherapy treatments

Environmental monitoring

To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment)

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To have a basic knowledge of socialization process

To promote socialization

Ability to evaluate and assess a socialization process

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations

To reinforce equality, diversity and transcultural approaches

To apply physiotherapy/massage techniques

To give positive suggestions to work team

To have basic knowledge of disrespectful or inappropriate circumstances

To know massage/physiotherapy techniques To know about home environment safety

To report environmental risks (to whom, how, with what times)

To guide ways of avoiding risks on home environment safety

To know good hygiene habits in home environment (cleaning, food etc.)

To report hygiene risks (to whom, how, with what times)

To evaluate appropriately the risks of unhygienic home environment

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Health monitoring

To interact with the elderly person in order to reinforce self-protection

To report any health risk (to whom, how, with what times)

To properly evaluate a mental and physical risk in home environment

To know the main indicators of risky conditions for physical and mental health (sudden illness, accidents, spread To take action to reduce the risks of infection, etc.)

To know how to help in medication adhesion To know healthcare organizations and services for older adults

Equipe working

To take action to reduce the risks

To provide planning schedules as reminders of medication

To interact for healthy behaviors in medical prescriptions

To guide the older adults on principals and existing services in the area that can make life easier

To motivate the usefulness / necessity of activation of a service.

To know how to support individuals To provide individuals with according to their personal information to enable them to care/support plan choose the way they want to be supported To know how to activate formal and To maintain social connection with informal support networks to stimulate medical personnel, social worker, active and healthy lifestyle neighbors and volunteers To know the role of other health/home care professionals

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To have a patient attitude in order to develop good habits

To ask for help from appropriate personnel when not confident or skilled in the role to carry out. To have communication skills and involvement of the older adults in the interactions.

To be able to respect other To encourage the elderly to health/home care professionals´ communicate with the network indications

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Administrative support

Activities of daily living support Activities for chair based exercise

To know the values and principles of adult social care

To know how to keep privacy of customer´s physical/ mental conditions

Reflect on holistic work practices

To know about administrative practices related to aging management

To support in complying fiscal practices and other practices relating to the older adults

To foster positive attitudes in fulfilling public rules

To know the importance of the elderly person´s privacy

To keep privacy about the elderly person´s reports

To respect the elderly person´s decisions

To know nutrition principals

To make personal nutritional plans

To assess foods on economic availability and food needs

To Know physical and mental conditions of older adults during accompaniment (falls risk assessment)

To assess on accompaniment risks

To suggest possible needs of devices or apparatus

To know how to identify, respond to and escalate changes to physical, social and emotional needs

To report changes to the correct professional , (to whom, when and where)

To motivate readaptation of the elderly person after changes

To monitor Socialization process

To know how to evaluate and assess a socialization process

To have the ability to promote socialization

To know local and national strategies for safeguarding and protection from abuse

To recognize potential signs of different forms of abuse

To support and challenge unsafe practices

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To report abuse (to whom, when and where) To know the barriers to communication (non-verbal communication, importance of active listening, etc.) To know structures and mechanisms of the human body in its development stages, in health and disease To know the values and principles of adult social care

To inspect carers under charge for correct practice

To know how to keep privacy of customer´s physical/mental conditions

To establish ways to communicate with the individual. (Establish signs, gestures, marks, communication boards, etc.) To have the ability of identifying erroneous treatments.

Reflect on own work practices

To know how to be aware of dementia

To report risks of dementia in older people (to whom, when and where)

To have the ability of approaching dementia without hurting sensibilities

To know the factors that can influence communication and interaction with individuals who have dementia

To know how to cope with individuals with dementia

To treat individuals with dementia under equal rights

To know quality methods and procedures Activities for older adults with special health needs

To know how to avoid barriers to communication

To know how to be aware of older people with diabetes

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To inspect quality of services

To encourage quality services to be kept

To monitor diabetes

To know how to prevent diabetes and/or early detection

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To know how to manage symptoms in end of life care

To prepare a life care plan

To know how to support individuals with loss and grief before death and/or specific communication needs To provide positive feedback to avoid doldrums or depressions

HHCP6 Physiotherapist Bachelor´s Degree (Level 4)

To know humanistic and holistic approach to the individual undergoing physical therapy treatment

To act according to the defined or observed needs

To be sensitized to individual needs and desires of the clients

To apply the selected physiotherapeutic procedures according to the clients’ needs

To approach his activities in accordance with ethical code of national physical therapists

To plan and program physiotherapeutic procedures

To evaluate treatment effects

To participate in team work, continuing professional education, and promotion of the profession.

To keeps records of clients´ treatments

To assure the privacy of records

To participate in prevention activities

To assess the nature of most convenient physiotherapy treatment

To monitor team work

To give positive advice to improve treatment

To assess the status of clients and the need for physiotherapeutic treatment Activities for physical therapy treatment

Activities concerning assessment to physiotherapy technicians/messeurs

To carry out kinesiometric and other measurements for the diagnosis of musculoskeletal and other systems functions

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HHCP7 Nursing University Degree (Master´s Degree) Environmental monitoring

To know home environment safety rules

To inspect monitoring environmental rules

To guide ways of avoiding risks on home environment safety

To know good hygiene habits in home environment (cleaning, food etc.)

To inspect that hygiene rules are complied with

To suggest how to comply with hygiene rules in a right way

To take action to reduce the risks

To interact with the elderly person in order to reinforce self-protection

To apply principal methods used in scientific research

To encourage the use of new methods used in scientific research

To know principal methods used in scientific research To know structures and mechanisms of the human body in health and disease To know quality methods and procedures

To inspect quality of services

To encourage quality services to be kept

Health monitoring To inspect monitoring of health risk To know main indicators of risky conditions for physical and mental health (sudden illness, accidents, spread To take action to reduce the risks of infection, etc.)

To know rules for medication adhesion

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To inspect monitoring of planning schedules as reminders of medication

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To evaluate that mental and physical to avoid risks in home environment are being followed To suggest changes in actions being taken To suggest changes for healthy behaviors in medical prescriptions

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To know healthcare organizations and services for older adults

To guide other professionals on principals and existing services in the area that can make life easier

To seek, understand and motivate information and use it creatively in problem solving

To know support networks to stimulate active and healthy lifestyle

To follow up maintain of social connection with medical personnel, social worker, neighbors and volunteers To monitor other health/home care professionals´ indications are being followed

To have communication skills and involvement of other professionals in the interactions.

Equipe working To monitor the role of other health/home care professionals

Teaching/Managing approach

To communicate in academic and clinical contexts (even in the English language)

To perform continually as a teacher for health staff and patients

To be able to communicate health- To be able and willing to act as rolerelated information model.

To know the values and principles of adult social care and medical laws

To inspect that customer´s and other professionals´ privacy is being complied with

To observe the rules of conduct of the institution

To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know medical informatics

To understand fundamentals of the patient medical history

To communicate clearly with colleagues (including physicians and allied health professionals)

To know the importance of the elderly person´s privacy

To inspect privacy monitoring of the elderly person´s reports

To suggest corrections on how to monitor privacy

To inspect personal nutritional plans monitoring

To make suggestions for foods on economic availability and food needs

To know nutrition principals

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To know devices and appliance equipment for elderly people

To know how to inspect Socialization process To know and recognize accurate diagnosis algorithms HHCP8 Physiotherapist University Degree (Master´s Degress)

To know principal methods used in scientific research

Teaching/Managing approach

To inspect that appliance equipment and devices are being used correctly

To assess workers under their charge on how to monitor de use of mechanical devices or appliance equipment

To evaluate and assess a better socialization process to other professionals monitoring the process

To have the ability to reconsider possible changes in socialization process

To know how to communicate diagnosis, treatment and prognosis to patient, patient´s family and other health professionals To apply principal methods used in scientific research

To have the ability to work in a team and give and execute orders with respect To encourage the use of new methods used in scientific research

To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know medical informatics

To understand fundamentals of the patient medical history

To communicate clearly with colleagues (including physicians and allied health professionals)

To know the importance of the elderly person´s privacy

To inspect privacy monitoring of the elderly person´s reports

To suggest corrections on how to monitor privacy

To inspect that appliance equipment and devices are being used correctly

To assess workers under their charge on how to monitor de use of mechanical devices or appliance equipment

To evaluate improvement of physiological treatments

To study continually new methods

To know devices and appliance equipment for elderly people

To know and recognize accurate diagnosis algorithms

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14.2.1 References http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971660/ (Table 3) http://www.zvu.hr/strucni-studij-fizioterapije/?lang=en

15 OLDER PERSONS HOMECARE IN CYPROS 15.1Overview on the older persons homecare service in Cypros Population rates in Cyprus are as follows: • • • • •

•

Total population as of 1 January, 2016: 1,177,091. Population over 65 years old: 10.4 % (122,235 persons over 64 years old). Dependency ratio for people over 65 years of age is 14.2 %. Women represent the largest number and proportion of elderly people. Total life expectancy at birth: 77.8 years. (Above the average of global population: 71 years, according to Population Division of the Department of Economic and Social Affairs of the United Nations). Cyprus became an independent sovereign republic in 1960. The constitution institutionalized communal dualism between the Greek and Turkish communities on the island in al spheres of government activity. Turkey occupied the northern part of the island in 1974, thus part of the country follows Greek habits and traditions whilst the other part follows Turkish traditions. According to labor force survey data, in 2011, foreign workers, including EU-27 nationals, represented 22.2 % of the total employment.

Home care nursing in Cyprus was first provided by mental health nurses in 1985. In the decade of 80s-90s, day centers were established with the help of local voluntary organizations and municipalities. Home care nursing services began in 2004 for people who qualified under the law “The Safeguarding and Protection of the Patients´ Rights Law”, 2004, article 6 (b). The Home Care Nursing program (community nurses) provides short term care (2 months) and long term care (more than 2 months). The nursing interventions provided include measurement of vital signs, change of wounds, removal of stitches, injections, check of glucose levels, health counseling, monitoring medicine prescription, personal hygiene, taking preventive measures, modification of the environment and blood collection. There are several nursing specialties: Community Psychiatric Nurses, Community General Nurses, Health Visitors, PASYKAF (specialized nurses for patients with cancer), but no specialization for Home Care, therefore when visits to the elderly people are necessary they is provided by community general nurses. Home care for the elderly is organized by the Social Welfare Services. Within the services for public assistance, the elderly and the disabled, public legislation incorporates employment incentives to encourage social inclusion and gradually end the reliance of public assistance recipients on public funds. The Social Welfare Services materialize a project which is co-financed by the European Social Fund and the Government of Cyprus through which public assistance recipients receive training. Upon its completion they are expected to be placed in the labor market. They have incorporated several programs in this regard: 1) Public Assistance, 2)

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Services for the Elderly and the Disable, 3) Schemes offered by the service for Public Assistance, the Elderly and the Disabled, 4) Benefits and Services provided to the Enclaved and 5) Composition of Social-economic reports. Social Welfare Services are in charge of home-care, day-care and residential care services. It is provided to people entitled to public assistance benefit or people who cannot meet their special needs by their income. The people interested in receiving the services have to fill in the Public Assistance Application Form and submit it to their District Social Welfare Services Office. The government encourages local communities and non-governmental organizations to develop supportive services on the local level in order to accommodate the needs of the people of their communities. Social Welfare Services employ carers but they can also be employed by Community Councils or may be selfemployed. The salary of the carers of the last two categories is paid by the Public Assistance Fund. Home care service provides personal hygiene, house-cleaning, washing the clothes, shopping, cooking, payment of bills, etc. but compared to the community nursing staff they are not educated or experts on the health/nursing care. Day-care service is aimed for people unable to care for themselves. They can spend their daytime at their local day-care center where they are offered cooked meals and laundry facilities. These centers are operated by the Community Welfare Councils and are financed by the Scheme of State Funding. Residential Care is strictly provided to people when their individual needs cannot be met on a 24 hour basis by their family or other supportive services. They can be governmental, community or privately owned residential homes. The Social Welfare Services are responsible for the registration and supervision for privately and community owned residential homes. A public program namely “Community Organization and Development” is aimed towards the organization and development of the communities, organized groups and voluntary organizations. This program also promotes the Institution of Community Welfare Councils on a local, regional and national level. They receive technical and financial assistance through the Grants in Aid Scheme from which Day Care Centers can benefit. Education in Cyprus.- Available from pre-primary to postgraduate levels. Primary (grades one to six) and lower secondary (grades seven to nine) are compulsory until the student reaches the age of 15. In upper secondary education (grades 10 to 12) which lasts for three years, there are two types of schools: the unified lyceum and technical schools. Tertiary education, including postgraduate courses, is provided at three public and four private universities, and several private colleges and institutions provide courses at the post-secondary nonuniversity level. Most students prefer to follow general education due to the prejudice against technical occupations. Moreover, the economy is mainly focused on the service sector declining manufacturing sector, so this has led to a decline in the number of students in technical schools. VET education.- The Ministry of Education and Culture (MoEC) has overall responsibility for the development and implementation of educational policy. The Ministry of Labor and Social Insurance (MLSI) has overall responsibility for labor and social policy. The Human Resource Development Authority (HRDA) plays an important role in vocational training. The HRDA is a semi-governmental organization whose mission is to create the prerequisites for the planned and systematic training and development of the human resources. 562634-EPP-1-2015-IT-EPPKA2-SSA

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The Foundation for the management of the European lifelong learning programs is the body which manages education programs and promotes the goals and the EU education and training policies in Cyprus. The earliest level at which VET is available is the upper secondary level at technical schools. VET is also available through the apprenticeship system, which accepts students who leave formal education between grades 8 to 10. VET training is extensively available for employees, the unemployed, other vulnerable groups and adults in general through a mixture of public and private provision such as colleges, training institutions, consultancy firms and enterprises. • New Modern Apprenticeship: A two year initial VET program (embracing two levels: preparatory and core) provides practical and theoretical training, mostly for young people from 14 to 25 years of age, who have not successfully completed their secondary compulsory education (and/or second grade of Gymnasium and have reached their 15th year of age) and wish to be trained and employed in technical occupations. It is focused on the current needs of the labor market (i.e. builders, plumber/welder, auto mechanic, auto electrician, furniture maker/carpenter, electrician, domestic appliances repairer and hairdresser). They receive the apprenticeship certificate when they successfully complete the course. This certificate allows access to several regulated occupations. • Elderly Care Vocational Certificate (ECVC): Certificate for informal, paid assistants and formal carers elearning program, aimed at assisting the elderly people in Cyprus and abroad. The Piraeus Chamber of Commerce and Industry in Greece supervises the theoretical and practical training of the trainee care workers that leads to an accepted EU level qualification. • VET upper secondary level: The duration of studies is three years for both types of course (theoretical pathway and practical pathway). School leaving certificates are awarded upon successful completion of either programs and are equivalent to secondary general education schools. Therefore they are eligible for admission to universities and other tertiary education institutions. • VET at post-secondary level: As part of the education reform, in 2012/13, the MoEC in cooperation with the MLSI and other stakeholders promoted a further technical specialization. (One and two-year programs including practical training in enterprises). • There are several other types of formal education, such as Evening technical schools, Public institutions of tertiary education (Higher Hotel Institute of Cyprus, Forestry College, Tourist Guides School, Cyprus Police Academy, naming just a few), Training for the unemployed, and Training for other groups at risk of exclusion from the labor market.

NQF framework implementation was completed quite recently (2013) and regulated professions have fully transposed the new Directive into national law (one for the general recognition of regulated professions and seven others for sectoral professions (nurse responsible for general care, dental practitioner, veterinary surgeon, midwife, architect, pharmacist and doctor)

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15.2HHCP involved in older persons homecare service in Cypros: roles and competences OCCUPATION - HCCP

ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge To know basics on how to do housework.

SKILLS know how to do - SKILLS as cognitive To keep hygienic conditions of the customer´s personal environment.

To use cleaning products in a proper way

To do daily housework

To have a positive attitude if the elderly person is untidy

To know basics of hygiene in home environment (cleaning, food etc.)

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To know basics on how to deliver meal services

To follow instructions on how to deliver meals correctly

To be able to care for meal services maintenance

To know how meal delivery services should proceed

To take action when meal service delivery is incorrect

To solve minor disorders when meal service delivery is unfit

To know basics physical and mental health conditions To know about normal physical deteriorating conditions in the elderly people To know basics about specific illnesses such as Parkinson, Arthritis, pneumonia, Diabetes, Alzheimer diseases

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

To know (how, when and to whom) report specific deteriorated conditions To know (how, when and to whom) report suspicions about existing diseases To know how to use specific products

To be able to give a positive view to the elderly person about the issue

Environmental monitoring

HHCP1 Non-Formal / Informal Carers ECVC Certificate (EQF Level 2-5)

Health monitoring

To know about incontinence

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COMPETENCIES know how to be

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To give a positive view to the elderly person on how to cope with the disease To be patient with the incontinent person

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To take action to reduce the risks To know basic ways of communicating risk conditions

To report any health risk (to whom, how and when)

To have basic ideas about domestic economy

Activities of daily living support

Values and principals

To be patient with mentally or physically disabled To communicate correctly those health risks to the elderly person and/or other personnel involved

To do shopping

To be motived on giving good advice about food to buy on the basis of economic availability and food needs

To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment)

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To have a basic knowledge of socialization process

To promote socialization

Ability to evaluate and assess a socialization process

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations

To reinforce equality, diversity and transcultural approaches

To know basics of nutrition

To have basic knowledge of disrespectful or inappropriate circumstances

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To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know the purpose of being a home carer

To manage the specific needs of the elderly person to be cared for

To have a positive attitude towards the elderly

To know basics about specific illnesses such as Diabetes, Parkinson, Pneumonia Alzheimer diseases

To know (how, when and to whom) to report intuition of possible specific illnesses

To have a positive attitude forwards elderly people with specific illnesses

To keep hygienic conditions of the customer´s personal environment.

To use cleaning products in a proper way

To do daily housework

To have a positive attitude if the elderly person is untidy

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To follow instructions on how to deliver meals correctly

To be able to care for meal services maintenance

To take action when meal service delivery is incorrect

To solve minor disorders when meal service delivery is unfit

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

To know basics on how to do housework. HHCP2 Non-Formal / Informal Carers Adults/NMA & others (EQF Level 4-5)

Environmental monitoring To know basics of hygiene in home environment (cleaning, food etc.)

Health monitoring

To know basics on how to deliver meal services To know how meal delivery services should proceed To know basics physical and mental health conditions

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To know about normal physical deteriorating conditions in the elderly people

To know (how, when and to whom) report specific deteriorated conditions

To be able to give a positive view to the elderly person about the issue

To know basics about specific illnesses such as Parkinson, Arthritis, pneumonia, Diabetes, Alzheimer diseases

To know (how, when and to whom) report suspicions about existing diseases

To give a positive view to the elderly person on how to cope with the disease

To know about incontinence

To know how to use specific products

To be patient with the incontinent person

To take action to reduce the risks To know basic ways of communicating risk conditions

Activities of daily living support

To report any health risk (to whom, how and when)

To have basic ideas about domestic economy

To be patient with mentally or physically disabled To communicate correctly those health risks to the elderly person and/or other personnel involved

To do shopping

To be motived on giving good advice about food to buy on the basis of economic availability and food needs

To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment)

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To have a basic knowledge of socialization process

To promote socialization

Ability to evaluate and assess a socialization process

To know basics of nutrition

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To know fire safety risks

To have basic knowledge of disrespectful or inappropriate circumstances

Values and principals

HHCP3 Community General Nurse (EQF Level 6-8)

Environmental monitoring Health monitoring

To know how to avoid fire risks

To have the ability of preventing fire risks

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations

To reinforce equality, diversity and transcultural approaches

To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know the purpose of being a home carer

To manage the specific needs of the elderly person to be cared for

To have a positive attitude towards the elderly

To know basics about specific illnesses such as Diabetes, Parkinson, Pneumonia Alzheimer diseases

To know (how, when and to whom) to report intuition of possible specific illnesses

To have a positive attitude forwards elderly people with specific illnesses

To know about home environment safety

To report environmental risks (to whom, how, with what times)

To guide ways of avoiding risks on home environment safety

To report hygiene risks (to whom, how, with what times)

To interact with the elderly person in order to reinforce self-protection

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

To know good hygiene habits in home environment (cleaning, food etc.)

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To give instructions to informal carers or relatives on how to keep good hygienic habits

To interact with the elderly person on how to keep clean.

To take action when meal service delivery is incorrect

To solve minor disorders when meal service delivery is unfit

To know the holistic approach to home care nursing and community-based nursing care

To apply the holistic approach to home care nursing

To find creative proposals for the elderly persons needs

To know about normal physical deteriorating conditions in the elderly people

To know (how, when and to whom) report specific deteriorated conditions

To be able to find positive guide ways to the elderly person

To know specific illnesses such as Parkinson, Arthritis, pneumonia, Diabetes, Alzheimer diseases

To know handle with existing diseases

To give a positive view to the elderly person on how to cope with the disease

To know how to use specific products

To give suggestions on how to settle inconveniences

To know good hygiene habits for personal self-care To know how meal delivery services should proceed

To know about incontinence

To take action to reduce the risks To know risky conditions in and out of the elderly persons home

Equipe working

To know healthcare organizations and services for older adults

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To know how to avoid risky conditions To guide the older adults on principals and existing services in the area that can make life easier

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To explain correctly how to avoid risks to the elderly and other persons involved in the caring To interact with the elderly person in order to reinforce self-protection To motivate the usefulness / necessity of activation of a service.

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To know how to support individuals To provide individuals with according to their personal information to enable them to care/support plan choose the way they want to be supported To know how to activate formal and To maintain social connection with informal support networks to stimulate medical personnel, social worker, active and healthy lifestyle neighbors and volunteers

Administrative support

Activities of daily living support Activities for chair based exercise

To ask for help from appropriate personnel when not confident or skilled in the role to carry out. To have communication skills and involvement of the older adults in the interactions.

To know the role of other health/home care professionals

To be able to respect other To encourage the elderly to health/home care professionals´ communicate with the network indications

To know the values and principles of adult social care

To know how to keep privacy of customer´s physical/ mental conditions

Reflect on holistic work practices

To know about administrative practices related to aging management

To support in complying fiscal practices and other practices relating to the older adults

To foster positive attitudes in fulfilling public rules

To know the importance of the elderly person´s privacy

To keep privacy about the elderly person´s reports

To respect the elderly person´s decisions

To know nutrition principals

To make personal nutritional plans

To assess foods on economic availability and food needs

To Know physical and mental conditions of older adults during accompaniment (falls risk assessment)

To assess on accompaniment risks

To suggest possible needs of devices or apparatus

To know how to identify, respond to and escalate changes to physical, social and emotional needs

To report changes to the correct professional , (to whom, when and where)

To motivate readaptation of the elderly person after changes

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To monitor Socialization process

To know how to evaluate and assess a socialization process

To have the ability to promote socialization

To know local and national strategies for safeguarding and protection from abuse

To recognize potential signs of different forms of abuse

To support and challenge unsafe practices

To report abuse (to whom, when and where) To know the barriers to communication (non-verbal communication, importance of active listening, etc.) To know structures and mechanisms of the human body in its development stages, in health and disease To know the values and principles of adult social care

To know how to avoid barriers to communication To inspect carers under charge for correct practice

To know how to keep privacy of customer´s physical/mental conditions

To establish ways to communicate with the individual. (Establish signs, gestures, marks, communication boards, etc.) To have the ability of identifying erroneous treatments.

Reflect on own work practices

To know how to be aware of dementia

To report risks of dementia in older people (to whom, when and where)

To have the ability of approaching dementia without hurting sensibilities

To know the factors that can influence communication and interaction with individuals who have dementia

To know how to cope with individuals with dementia

To treat individuals with dementia under equal rights

To know quality methods and procedures

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To inspect quality of services

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To encourage quality services to be kept

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To know how to be aware of older people with diabetes and other specific diseases

Activities for older adults with special health needs

To know how to manage symptoms in end of life care

To monitor specific disease

To prepare a life care plan

To know how to prevent specific disease and/or early detection To know how to support individuals with loss and grief before death and/or specific communication needs To provide positive feedback to avoid doldrums or depressions

HHCP4 Physiotherapist Bachelor´s Degree (Level 6)

To know humanistic and holistic approach to the individual undergoing physical therapy treatment

To act according to the defined or observed needs

To be sensitized to individual needs and desires of the clients

To apply the selected physiotherapeutic procedures according to the clients’ needs

To approach the activities in accordance with ethical code of national physical therapists

To plan and program physiotherapeutic procedures

To evaluate treatment effects

To participate in team work, continuing professional education, and promotion of the profession.

To keeps records of clients´ treatments

To assure the privacy of records

To participate in prevention activities

To assess the status of clients and the need for physiotherapeutic treatment Activities for physical therapy treatment

To carry out kinesiometric and other measurements for the diagnosis of musculoskeletal and other systems functions

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Activities concerning assessment to physiotherapy technicians/messeurs

Environmental monitoring

HHCP5 Nursing University Degree (Master´s Degree Level 7-8)

To assess the nature of most convenient physiotherapy treatment

To monitor team work

To give positive advice to improve treatment

To know home environment safety rules

To inspect monitoring environmental rules

To guide ways of avoiding risks on home environment safety

To know good hygiene habits in home environment (cleaning, food etc.)

To inspect that hygiene rules are complied with

To suggest how to comply with hygiene rules in a right way

To take action to reduce the risks

To interact with the elderly person in order to reinforce self-protection

To apply principal methods used in scientific research

To encourage the use of new methods used in scientific research

To inspect quality of services

To encourage quality services to be kept

To know principal methods used in scientific research To know structures and mechanisms of the human body in health and disease Health monitoring To know quality methods and procedures

To inspect monitoring of health risk To know main indicators of risky conditions for physical and mental health (sudden illness, accidents, spread

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Equipe working

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of infection, etc.)

To take action to reduce the risks

To suggest changes in actions being taken

To know rules for medication adhesion

To inspect monitoring of planning schedules as reminders of medication

To suggest changes for healthy behaviors in medical prescriptions

To know healthcare organizations and services for older adults

To guide other professionals on principals and existing services in the area that can make life easier

To seek, understand and motivate information and use it creatively in problem solving

To know support networks to stimulate active and healthy lifestyle

To follow up maintain of social connection with medical personnel, social worker, neighbors and volunteers To monitor other health/home care professionals´ indications are being followed

To have communication skills and involvement of other professionals in the interactions.

To monitor the role of other health/home care professionals

To communicate in academic and clinical contexts (even in the English language)

To perform continually as a teacher for health staff and patients

To be able to communicate health- To be able and willing to act as rolerelated information model.

To know the values and principles of adult social care and medical laws

To inspect that customer´s and other professionals´ privacy is being complied with

To observe the rules of conduct of the institution

To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know medical informatics

To understand fundamentals of the patient medical history

To communicate clearly with colleagues (including physicians and allied health professionals)

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To know the importance of the elderly person´s privacy

To know nutrition principals To know devices and appliance equipment for elderly people

To know how to inspect Socialization process To know and recognize accurate diagnosis algorithms To know principal methods used in scientific research HHCP6 Physiotherapist University Degree (Master´s Degress)

Teaching/Managing approach

To inspect privacy monitoring of the elderly person´s reports

To suggest corrections on how to monitor privacy

To inspect personal nutritional plans monitoring

To make suggestions for foods on economic availability and food needs

To inspect that appliance equipment and devices are being used correctly

To assess workers under their charge on how to monitor de use of mechanical devices or appliance equipment

To evaluate and assess a better socialization process to other professionals monitoring the process

To have the ability to reconsider possible changes in socialization process

To know how to communicate diagnosis, treatment and prognosis to patient, patient´s family and other health professionals To apply principal methods used in scientific research

To have the ability to work in a team and give and execute orders with respect To encourage the use of new methods used in scientific research

To know administrative practices related to aging management

To inspect reports are correctly fulfilled

To communicate clearly in both verbal and written form for acuteness in reports

To know medical informatics

To understand fundamentals of the patient medical history

To communicate clearly with colleagues (including physicians and allied health professionals)

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To know the importance of the elderly person´s privacy

To know devices and appliance equipment for elderly people

To know and recognize accurate diagnosis algorithms

To inspect privacy monitoring of the elderly person´s reports

To suggest corrections on how to monitor privacy

To inspect that appliance equipment and devices are being used correctly

To assess workers under their charge on how to monitor de use of mechanical devices or appliance equipment

To evaluate improvement of physiological treatments

To study continually new methods

15.2.1 REFERENCES

http://www.euro.who.int/__data/assets/pdf_file/0008/181799/e96757.pdf www.cedefop.europa.eu/files/4118_en.pdf http://countrymeters.info/en/Cyprus http://www.mlsi.gov.cy/mlsi/sws/sws.nsf/All/51950D3157907F4AC2256E7700387B35?OpenDocument&print http://infocyprus.com/citizen/social-welfare/disability-and-illness/long-term-care-services http://study.com/articles/Home_Care_Assistant_Job_Description_Duties_and_Requirements.html

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16 OLDER PERSONS HOMECARE IN CZECH REPUBLIC 16.1 Overview on the older persons homecare service in Czech Republic The Risk of social exclusion of population over 65 years old in this country lower with respect to the other EU27 , the estimation of Eurostat 15/02/2011 is 11,7% , even if Czech Republic struggle with an overall ageing population, the percentage of over 65 in 2012 was 16.2% [World Bank 2014] at it has been estimated to increase at 20.2% in 2020 and 30.9% in 2050 [European Commission, 2009 Ageing Report]. The main reason of this is due to high percentage of informal care provided by relatives of old people. Even if there are no systematic research on informal care for elderly in Czech Republic [Holmerovà, 2004] the estimation of informal care providers is about 4-5 hundred of thousand persons [Sowa 2010] and the 80% of care is provided by the family. The total volume of informal care provided was reported to be 7.6 million hours per week, mainly provided in the form of household support (Hrkal et al., 2011). For this reason the perception that people have about the homecare is almost a minor needs generally perceived for severe disability [Nivel project 2012]. In Czech Republic, as well as in the majority of the other Eu country, Home-Care services are a combination of health and social care to be provided in the social environment of the needy person. Netherless the definition, there is a strong competition between medical care and social care that impairs the home-care infrastructureregions, so they do not have a dense network of home care. Home care services are dived over 2 ministry and the Home-Care schemes are divided according to the type of services: (ii) health services or health care which comes under the Ministry of Health and (ii) social services, supervised by the Ministry of Labour and Social Affairs. The Social Services Act 2006 tried to improve the coordination between the two systems, social-care and health-care, by allowing cross-funding between the two system and flexible care allowance but this coordination is still imperfect mainly due to the strong financial incentives for patients to remain in health-care facilities, even unjustified. The flexible individual care allowance has also enabled some patients to pay for care by family members or volunteers. (Alexa et al. 2015). Unfortunately up to now results of such coordination are poor but are planned new law to support the integration of services.

16.1.1 REGULATION The regulation is not at national level but at regional or mixed national and municipal level. Unfortunately there is an explicit policy document only for one type of home-care. The compulsory health insurance (Act no. 48/ 1997 Col. on Public Health Insurance) funds the health care as well as the provision of home nursing (including personal care) and rehabilitation at home. Nursing is intended

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to care for persons after hospital or for chronical patients, and in general for qualified care provided by professional nurse. The ways of reimbursement and the cost limits are addressed in the List of Diagnostic and Therapeutic Acts – Decree of the Ministry of Health Care 134/1998 Col. The qualifications and responsibilities of the professional team members, for health care services, are regulated (Acts nos. 95 and 96/2004 Col., and Decree of the Ministry of Health Care 424/2004 Col., on Responsibilities of the Non-Medical Staff) as well as the required equipment of home care agencies (Decree no. 49/1993 Col.), which stipulate for detailed material and technical equipment of the agencies, as well as for the criteria of professional qualifications of the caregivers. Instead the provision of long-term care, including home care, is covered by social care services based on tax money and provided by municipalities. The Law on Social Services (2006-2007) regulates the provision of home care, access to cash benefits for individuals with limitation in ADL and different types of residential care. The quality of social services is regulated by law (108/2006 Sb) and it is frequently checked by the municipalities, so the care providers are obliged to develop internal standards over the compulsory registration (social act 108/2006 Sb). As briefly cited, health insurance is compulsory in the Czech Republic, in any case individuals are allowed to choose their health insurance fund and to switch to a new fund every 12 months. Risk selection is not permitted so insurance funds are obliged to accept any applicant.

16.1.2 HOME-CARE PROVIDED SERVICES There are two types of care provided to the old persons home (Sowa, 2010): home care and home nursing care. Home care includes personal assistance services and community care in ADL, i.e. dressing, washing, shopping, meals and transport. Home nursing care, or Comprehensive Home Care, introduced in 1990, is a combination of home health and assistance covering partially the outpatient care. It combines nursing and rehabilitation provided by the consultancy of the doctor and the typical activities includes assistance in medicines, blood pressure measuring, taking blood… The practitioners more involved in home care and home nursing care are Nurses and Volunteers from private or no-profit agency. It has been estimated that the 58% of homecare agency provides care during night and weekends, the 22% during weekends and 20% in the afternoons (Sowa 2010). There are severe regional disparities on the provided services, for examples rural regions have scarse specialised care services and the cost of transportation of patients, to doctors or rehabilitation services, are not always possible. The problem of unequal regional distribution of home care services and home care agencies, within the lack of a unique vision of home-care (each of the ministries develops different measures and policy) increase the difficulties in recruit specific policy on required competences for home care practitioner, only for few figures that required s specific qualification.

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The services provided are, according to the definitions of project Nivel (Home Care across Europe, 2012): -

Domestic care ADL care Nursing care Provision of aids Support for informal caregivers

16.2HHCP involved in older persons homecare service in Czech Republic: roles and competences The ministry of health accredits post graduate training programmes for nurses and paramedical personnel, but in general no qualification for home-care services is required in Czech Republic only few domestic aid professionals were qualified. The professions related to the home care that have particular qualification requirement are (Jiří Horecký, 2010): Nurses: there are two types of nurses after the reform of 2007: Nurse Assistant. With a qualification of secondary school with a graduation, duty to take longterm education and to gather a certain number of credits. Nurse. University degree is required to be a full nurse Social Workers, ergotherapists different possible qualification are required: 1. Secondary upper school (7 years) or higher education in the field. 2. Any university degree combined with 200 hours expert course. 3. Duty of long-term education in the extent of 24 hours a year. Employees in social services i.e. a worker who does the helping/basic social care lined by the Social Services Act, that required a qualification of: 1. Basic education combined with 150 hours expert course. 2. Duty of long-term education in the extent of 24 hours a year. Unfortunately there are no evidences about the specific activities performed at old person’s home by Social Workers and Employees in social services, and for this reason it is difficult to found the required competences. Similarly in the Czech Statistical yearbook (2008, Social Security) the home care service workers identified are only (i) Professional nurses and (ii) Others the only other figure related to the activities performed at home are the volunteers in agreement to what already described. No updated data are available from this source. OECD- Health Statistics in 2015 identify the number of persons working in healthcare and social work in EU27. Czech Republic has 339 300 healthcare practitioners in 2013, with respect to a population of around 10.5 million people. Of those practitioners, Nurses were 84 045, Physiotherapists 8 133 and Caring Personnel 24 261. Following the definition of OECD Caring Personnel is an health care assistants in institutions and Home-based personal care workers (ISCO-08 5322 Practising caring personnel-personal care workers). It includes: - Providers caring personnel working in health and social establishments. - Professions: auxiliary nurses, social care workers (direct activities and home care activities). This means that the definition of Caring Personnel includes the Nurse Assistant and the Social Workers previously introduced. 562634-EPP-1-2015-IT-EPPKA2-SSA

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NURSES In this document we refer only to practitioner with University degree, classified according to the ISCO 08 with codes 2221. Nurses are mainly connected to the health care treatment. They are in charge to enhance and preserve health, prevent and treat illnesses and conditions, support rehabilitation, and conduct palliative care where there is no cure. They can be in charge of for the planning and management of the care of patients, working autonomously or in teams with medical doctors and others in the practical application of preventive and curative measures. Among performed activities can be listed: professional qualified care; assistance with mobility; assistance/supervision taking medication; assistance with personal hygiene; assistance dealing with incontinence and/or skin care. The Czech Republic neither signed or ratified the European Agreement on the Instruction and Education of Nurses (CETS No.059). No specific information about Czech nurses competencies have been retrieved. CARING PERSONNEL In this document we refer only to practitioner without a University degree, classified according to the ISCO 08 with code 5322 and 5329, i.e. associated/auxiliary nurses and social workers. To provide routine personal care and assistance with activities of daily living to persons who are in need of such care due to effects of ageing, illness, injury, or other physical or mental condition in private homes and other independent residential settings. Caring personnel usually perform the following activities: -

assistance with eating and drinking (not the preparation of food); assistance dealing with incontinence and/or skin care (available if classed as part of home care); services offering companionship and social activities (some are on voluntary bases) assistance dealing with incontinence and/or skin care (available if classed as part of home care) services offering companionship and social activities (some are on voluntary bases) ergotherapy/occupational therapy, home adaptations and assistive devices.

No specific information about Czech caring personnel competencies have been retrieved. VOLUNTEER Any specific education is required for the home helpers. The activities they usually perform are: -

assistance with housework; help with the preparation of meals (including meals-on-wheels); transportation service; assistance with shopping (non in all the municipalities).

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16.2.1 References Home care across Europe: Current structure and future challenges, Observatory Studies Series 27, WHO 2012, ISBN 978 92890 02882, Nivel project. http://ec.europa.eu/eurostat/statistics-explained/index.php/Healthcare_personnel_statistics__nursing_and_caring_professionals#Healthcare_personnel_.E2.80.94_nursing_professionals World Bank 2014, http://www.worldbank.org/en/about/annual-report European Commission, 2009 Ageing Report, http://ec.europa.eu/economy_finance/publications/publication14992_en.pdf. Holmerovà I, 2004, Eurofamcare National Background Report for the Czech Republic Sowa Agnieszka 2010, “ The Long-Term Care System For the Elderly in the Czech Republic”, ANCIEN, ISBN 97894-6138-014-2, ENEPRI Research report No. 72. Hrkal J, Bareš P, Daňková Š, Malečková R, Roubal T, Prošková E (2011). Analýza kapacit a sítě poskytovatelů dlouhodobé péče [Analysis of capacities and networks for long-term care]. http://podporaprocesu.cz/wpcontent/uploads/2013/01/Analyza_kapacit.pdf. Jan Alexa, Jana Votàpkovà, Ewout van Ginneken, Anne Spranger, Friedrich Writtenbecher, 2015, Czech Republic – Health system review, Health Systems in Transition, Vol.17, no. 1, 2015 Jiří Horecký, 2010, Current situation in quality of residential care, Long-Term care in the Czech Republic OECD- Health Statistics in 2015, http://www.oecd.org/els/health-systems/health-data.htm Czech Statistical Office, Czech Statistical Yearbook 2008, Paragraph on Social Security , www.czo.cz

17 OLDER PERSONS HOMECARE IN DENMARK 17.1Introduction to older persons homecare service in Denmark Background information about dementia and home care services In 1987, legislation more or less put a stop to the construction of conventional nursing homes for older people and encouraged the development of independent specialised housing as well as home care services (Leeson, 2004). The current trend is to try to enable people to remain at home for as long as possible. In Denmark, there is a classification system based on age with people over 60 forming the 3rd age group and those over 80 the 4th age group. There are approximately 700,000 people over the age of 67 in Denmark (the official retirement age). Of these, 172,000 receive long-term home-help and a further 7000 to 8000 people receive temporary home-help. The vast majority of people receiving long-term home-help live in their own homes. (Leeson, 2004). Jarden and Jarden (2002) estimate that there are about 189,000 people over 80 in Denmark. A high percentage of the 4th age group receive home care services. 562634-EPP-1-2015-IT-EPPKA2-SSA

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Legislation relating to the provision of home care services The Law on Social Assistance (1976) states that all communes must provide home help for the elderly. There is no difference between the social protection offered to people suffering from dementia and that offered to people who are dependent. The Social Service Legislation contains a few relevant references (taken from Leeson, 2004): According to paragraph 67a of the Social Services Legislation, local or regional authorities must determine whether there are any relatives or other people who could represent the older person i.e. in an advocacy role. Paragraph 71 part 60 states that local authorities should take into consideration the global situation of the older person, including the overall network, when assessing the need for assistance. Relatives are expected to participate in supporting the older person in the home. It is also suggested in part 96 of paragraph 71 that a relative should assist in completing the various application forms and that everyone should be made aware of this possibility. Paragraph 72 deals with respite care. It states that local authorities are obliged to provide respite help to spouses, parents or other close relatives caring for a physically or mentally disabled person. Organisation and financing of home care services The Danish healthcare system provides free and equal access to health care to all residents. It is funded through general taxation but access to care is not dependent on a person’s financial status. Home care is divided into two categories - long-term or temporary. Long-term home care is provided free of charge but people may be asked to contribute towards the costs of temporary home care depending on the level of their income (Jarden and Jarden, 2002). According to the Ministry of Social Affairs (2002), a goal has been established to improve the organisation of dementia care in order to ensure good coordination between local authority services and the provision of treatment and care by the health service. Furthermore, the development of partnerships between the public and voluntary sectors is emphasised, for example in areas such as respite care. Since 1989, the Integrated Home Service has encouraged medical personnel to work in the home care sector and social workers to work in medical institutions which permits a more flexible approach to home care particularly in times of need. Since 1 July 1989, dependent elderly people have been entitled to permanent and free home help. Such assistance is offered following an assessment of the functional capacity of the person, of his or her needs and on the basis of the service level determined by the local authority (Ministry of the Interior and Health/Ministry of Social Affairs and Gender Equality, 2002). In accordance with the Preventive Home Visits to the Ageing Law of July 1996, local authorities are obliged to offer preventive home visits to all citizens over 75 years of age at least twice a year. The aim of these visits is to encourage older people to use their own resources better and consequently allow them to preserve their functional capacities as long as possible and also to be informed of the resources available from the municipality. The elderly person can freely decide whether or not to accept the home visit and can decide which subjects should be discussed.

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Since 1 July 2002, people receiving personal or practical services have been entitled to exchange the services that they have been allocated for other services that they would prefer (Ministry of the Interior and Health/Ministry of Social Affairs and Gender Equality, 2002). Since 1 January 2003, older people have had the right to choose the providers of the personal and practical help and assistance to which they are entitled. Local authorities therefore have to ensure that there are several service providers from which to choose. The older person can then decide whether they would prefer the help with personal care and/or practical tasks to be provided by a private person, the local authority or an authorised service provider. This means that a family member could be chosen and would be paid by the local authority. This had been possible for a long time for practical help but it has now been extended to encompass personal care (Jarden and Jarden, 2002). Kinds of home care services available Local authorities must provide nursing care in service users’ homes and offer help and assistance to maintain physical and mental capacity. Such assistance should be provided in such a way that it encourages the participation of the older people and helps them to manage alone thereby maintaining their autonomy for as long as possible. Home care services may include 24 hour assistance from a nurse, the provision of meals, the possibility to adapt the home, day care centres, financial assistance and transport facilities. Sometimes this may also include having an alarm system, maintaining the garden and clearing away snow. Certain services, such as minor repair jobs, are not provided by the local authorities. Some voluntary associations offer assistance with such jobs. Otherwise, the person can purchase the services from the private sector. Meals may be delivered to the home by the local authorities at a subsidised rate. They are sometimes prepared in residential homes and then distributed within the community. Day care centres also have meals facilities. Local authorities may also provide or finance services aimed at keeping people active or promoting their health. Sometimes, such services are proposed and/or organised by voluntary associations but financed by the local authorities. Such services might include sports activities, tuition/lectures and companionship for older people who are lonely. In 1998, the Social Service Law introduced a yearly budget for the development and expansion of voluntary services (Jarden and Jarden, 2002). DaneAge is an association, with a nationwide network, which offers older people a wide range of activities and opportunities to socialise. It also provides respite care for carers of people with dementia and trains volunteers so that they can provide such services in people’s homes. These volunteers are of all ages and from all walks of life (Leeson, 2004). Respite care is also offered by some nursing homes. Consultation with people with dementia and carers At the request of the Ministry of Social Affairs, 8 communes took part in a project based on home care for elderly people with dementia and their families. Some of the communes sent out questionnaires to obtain qualitative and quantitative information on the needs of the people with dementia and their carers. The municipality of Vejle organised a project aimed at assessing users’ satisfaction with home care services, getting a picture of how resources were used, establishing a common notion of what quality and quality objectives are and drawing up a plan for the achievement of defined objectives. Users, employees and politicians were all involved in the project. Users were involved in drawing up the questionnaires. There were also group and individual interviews for which the elderly-talk-to-elderly method was used. It was felt that 562634-EPP-1-2015-IT-EPPKA2-SSA

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involvement of users and an elderly persons council was effective in motivating people. (This project was not limited to people with dementia.) (EFILWC, 2002) The situation on home care in Denmark Healthcare and welfare is primarily governed by the Health Act and Social Services Act. Currently, there are much focus on rehabilitation - the citizen must be able to fend for themselves as long as possible in their own lives, as well as increased privatization and including free-choice scheme which allows the citizen to choose between public or private homecare. Generally, welfare and services in Denmark are under pressure due to longstanding savings and cut downs in the municipalities. This may explain the increasing focus on rehabilitation because it wishes to prevent admissions / readmissions and improve the work of early detection, so the cost of the elderly and infirm citizens is held down.

17.2HHCP involved in older persons homecare service in Denmark: roles and competences In Denmark can be identified two kinds of practical nurses/healthcareworkers in the homecare-sector: Socialand health service assistants and Social- and health service helpers.

17.2.1 Social- and health service assistants Social- and health service assistants works within a variety of workareas. Common to the worktasks is basic healthcare- and nursing for citizens/patients. Social- and health service assistants work on a daily basis with people with a need for basic healthcare and nursing eg. elderly citizens , patients in hospitals , mentally ill or people with physical or mentally disability. Typical workplaces is within the municipal healthcare, in psychiatric and in hospitals. Social- and health service assistants is authorized healthcarepersons. Today there is around 35.000 Social- and healthcare assistants in Denmark divided in regions and municipalities. Social- and health service assistants perform basic nursing tasks in nursing homes, home care, psychiatry and hospitals. The tasks may include personal care, performing delegated treatment, clinical nursing tasks, medication, conversations, coordination of citizensprogress, rehabilitation, everyday-rehabilitation and other activity with residents or patients. Social- and health service assistants must also independently perform and organize rehabilitative tasks for citizens. It can be related to activities that stimulate physical, intellectual and creative features. Social and healthcare assistants may be employed in a variety of jobs, and can have many different jobs. The most specific role is basic nursing, observation, identification of symptoms, rehabilitation, guidance, instruction and information that are central tasks. Social and health service assistants can take the role of supervisor of students in social- and healthcare educational institutions. Social and health assistants are employed under the Health Act.

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17.2.2 Social- and health service helper Social- and health service helper perform a variety of tasks in care and practical help, but are not employed in hospitals. A social- and health service helper is focusing on the well-being and care of the citizens. Social- and health service helpers work on a daily basis typically with senior citizens who may be sick or influenced by old age symptoms. Social- and health service helpers are also working with people with physical and mental disabilities, and as a reliefperson in the care of people with severe disabilities. Social- and health service helpers can work within all hours of the day. Social- and health service helpers are employed under the Social Services Act. Social- and health service helpers are providing care and practical help (cleaning, shopping and laundry) to citizens who need support and help to maintain a normal daily life. Social- and health service helpers have the skills to observe and recognize the symptoms of changing welfare and health conditions. Social- and health service helpers must be able to explain and document these observations. In this context, social- and health service helpers must be aware of their responsibilities and area of competence. As a social- and health service helper you must also work with motivationtasks and enable citizens to develop, maintain and preserve their resources (rehabilitating). To ensure a coordinated and coherent assistance to the citizens social- and health service helpers have a lot of contact with other professionals. Social- and health service helpers can take the role of supervisor of students in social- and healthcare educational institutions.

17.2.3 References European Foundation for the Improvement of Living and Working Conditions (EFILWC) (2002), Denmark – http://www.eirpfpimd.ie/living /socpub_cstudies/de3.htm (accessed 31/5/2005) Jarden and Jarden (2002), Social and health-care policy for the elderly in Denmark, Global Action on Aging, http://www.globalaging.org/elderrights/world/densocialhealthcare.htm Leeson, G.W. (2004), National Background Report for Denmark, EUROFAMCARE,http://www.uke.unihamburg.de/extern/eurofamcare/documents/nabare_denmark_rc1_a4.pdf Ministry of the Interior and Health & Ministry of Social Affairs and Gender Equality (2002), Questionnaire on health and long-term care for the elderly, European Commission http://europa.eu.int/comm/employment_social/social_protection/health_en.htm Witsoe-Lund, L. and Ibenfeldt-Schultz, L., Le système d’aide et de soins aux personnes âgées atteintes de démence sénile de type Alzheimer au Danemark. In Joël, M.-E. et Cozette, E. (2002), Prise en charge de la maladie d’Alzheimer en Europe, Inserm

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18 OLDER PERSONS HOMECARE IN ESTONIA 18.1Introduction to older persons homecare service in Estonia In 1. January 2016, the population of Estonia was 1,311 800 (https://www.stat.ee/12808). Since 1990 the number of births has been diminishing, the number of deaths has been growing and the population deceasing (forecast for 20130 is 1,2 millions). The proportion of people aged 65-74 years has increased from 11.6% in 1990 to 17.1% in 2009 (Statistical Office of Estonia 2009). The population of very old persons (80 and over) is expected to increase from 4,8 % (2013) to 7,2 % (2030). The life expectancies at bright are increasing from 71,6 years (2013) to 75,7 years (2030) by male and from 81,3 years (2013) to 84,1 years by female. In Estonia, there is a high percentage of elderly people, particularly elderly single women living alone. An estimated 10% of the residents of age over 65 need the geriatric evaluation team service (www.ubc.net_2966). (http://europa.eu/epc/pdf/ageing_report_2015_en.pdf) Estonia gained independence in 1918 and again in 1991. From 1991 to 2000, new principles of social security were formed and new insurance systems were established. The Estonian health care system has seen a number of reforms: changing from a centralized state-controlled system to a decentralized one and from a state-funded system to one funded mainly through health insurance contributions. In 2001, the Ministry of Social Affairs (MoSA) prepared the Nursing Care Master Plan 2015 in order to provide nursing care targets to match the hospital targets set out in the Hospital Master Plan 2015. Reforms in the healthcare system are closely linked to the social welfare system. The Social Welfare Act (Sotsiaalhooldekande seadus RT I, 30.12.2015, 5: https://www.riigiteataja.ee/akt/130122015005) covers the provision of home care services which are defined as being services provided to persons in their homes which help them to cope in familiar surroundings. The Act states that local government authorities shall establish a list of home care services and the conditions and procedure for their provision as well name a carer to persons (the Social Welfare Act § 28/1). Rural municipality governments and city governments shall establish opportunities for cheaper alimentation, opportunities for interaction and hobbies, ensure the accessibility of information concerning services provided and establish opportunities for the use of social services as well the security and independence of the elderly living in social welfare institutions, respect for their private life and the opportunity to participate in decisionmaking pertaining to their physical and social environment and future in order to assist the elderly (the Social Welfare Act §27). Long-term services comprise welfare and nursing services. The systems for health care and social welfare are relatively separate. Funding for social welfare comes from local government budgets, the state budget, people who voluntarily engage in social welfare and various other sources. The state budget provides local governments with funds for social welfare but the local governments may also have to use their own budgets for this purpose. Voluntary organizations, churches, foundations, commercial associations and non-profit organizations can all provide social services. People who are in need of services must contact their local government in order to organize for a social worker to assess their needs and determine the kind of care they will receive (based on their needs and financial situation). Elderly people may be offered a geriatric assessment (from 2004) and it consist of a single assessment to determine clients’ needs and to provide them with suitable services covering health care,

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nursing care and welfare services. The geriatric assessment team is composed of a physician, a nurse and a social worker and an international standardized tool is used for the assessment. In case of needing assistance people can receive various care services according to the needs and available resources. The providers of social services may charge beneficiaries or their families for their services. Children and kinsfolk are legally obliged to take care of their elderly relatives. However, if they are unable to do so or if an elderly person does not have any relatives, the Government must assume responsibility for their care. Estonian Health Insurance Fond (HIF) covers the costs of the service in case of a referral letter from GP or medical specialist. Medications used during home care service shall be paid by the patient. In the Law on Social Welfare (Social Welfare Act RT I, 30.12.2015, 5: https://www.riigiteataja.ee/akt/130122015005), home care services are defined as services provided to persons in their homes which help them cope in familiar surroundings and it is stated that a list of domestic services and the conditions and procedure for their provision shall be established by local government authorities. Welfare services are: Home services – services offered to persons at home, helping them with coping in their usual environment; excluding the care that requires physical contact. The local government is responsible for assuring long-term aid to those living at home, making sure they have access to general public services. Home services are household chores, procurement of food, pharmaceuticals, other necessities and firewood or other fuel, information and assistance in administrative matters, etc. Accommodation or housing service (including adaptation) – supplying facilities for 24 hour accommodation, including rental of accommodation. Service providers are either a local government or a private company. Services include making necessary adaptations for more comfortable mobility and security in the room. Personal assistance service – helping persons with low coping ability to perform activities, helping them to move around, in issues of personal hygiene, administrative matters at home and outside. Service is provided by local government. Day care in a welfare institution - supporting a person's or his/her family's coping capacity in institutions where the person spends the day. Long-term care in institution Nursing services are regulated by Regulation of Ministry of Social Affairs („Iseseisvalt osutatavate õendusabi tervishoiuteenuste loetelu“ 10.01.2002, nr 11, RTL 2002, 14, 178). In 2003 the Estonian Health Insurance Fund started to cover expenses for long-term care, nursing care and some home care. There are follow services offered at home: • • •

Home care (Koduhooldus) –for people of all ages in case of need some assistance at home Home nursing care nursing and welfare services to improve the clients' health and welfare, supporting their livelihoods and homes in the community. Home nursing care is a part of open care (Avahooldus). Official or formal care (Ametlik ehk formaalne hooldus) – services provided to salaried employees which support or supplement informal care (sometimes replace them).

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Informal care (Mitteametlik ehk mitteformaalne hooldus) - care or basic nursing care of an elderly or disabled family member or a relative in home conditions by relatives or family care of a person in a suitable family where he/she is not a member of the family. Local governments offer supporting services to help the carers and to pay compensation to cover the costs related to caring, which is not a remuneration/salary.

Home care nurse service offers support to patient´s family and intimates who need counseling in nursing activities. Home care is only available if the procedure needed does not require any special equipment. A home care nurse has a special training in the field of providing in-home nursing services. The nurse draws a caring plan according to patient´s needs and diagnosis. The plan gives guidelines for further activities: bandaging, collecting analyzes, administrating medications, measuring blood pressure, bedsores treatment and other. Nursing service is conducted in close collaboration with patient´s doctor and intimates and local social worker or caregiver if indicated. Home care nursing is possible by following pre-conditions: patient’s medical condition does not require hospital treatment, but requires nursing services; patient and his/her family agree to the service and collaboration; home offers suitable conditions for undergoing the procedures; patient and his/her intimates are emotionally supportive towards the service. A patient and a nurse sign a contract, which gives the nurse rights to perform home care services at patient´s home. (http://www.itk.ee/en/clinics/long-term-nursing-clinic/about-nursingclinic/long-term-nursing-center/homecare-service.) Home care nurse, as well care worker and nurse (planner and organizer) work in home care team. Active members in home care are home care nurse (EQF4) and care worker (EQF3). Nurses will participate only as external experts by planning care plan. Older people will visits their doctors who will be responsible in decisions and medicaments. (http://www.sm.ee/sites/default/files/contenteditors/eesmargid_ja_tegevused/Tervis/Tervishoiususteem/koduoenduse_tegevusjuhend.pdf). There are over 200 municipalities in Estonia and many of them are very small. For this reason, it is impossible for them all to offer a full range of services. Nevertheless, home care services are offered mostly in bigger towns and only for persons who have got any relatives. Older persons or their families can hire themselves a private carer (friend, voluntaries, student etc.). Access to the official home care services is quite difficult. There are need to offer home nursing around Estonia 7 days per week and 24 hours. The average number of visits per working day is 4 -6 clients but in country side maximum is 4 clients. The home care practitioners use the most time for guidance and support of client (20 %), assistance in daily activities (17 %) and for caring and nursing (15 %) as well for procedures (9 %). Example in capital of Estonia, Tallinn, the average number of visits per month for one patient is 15; this allows one nurse to deal with 70-80 patients every year, making approx. 1320 visits annually (http://www.sm.ee/et/hooldaja-maaramine-koduhooldus).

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18.2HHCP involved in older persons homecare service in Estonia: roles and competences CARE WORKER (EQF3) ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

Household chores

Knows practical principles of household and cleaning Knows living environment of elderly people Knows income security Knows nutrition and healthy diet

Has skills in household chores (cleaning, washing, taking care of clothes), procurement of food and shopping, other necessities and firewood or other fuel Notices a healthy diet and nutrition Supports a person's by outdoors activities (by going to shop, bank etc. administrative matters)

Organizes domestic work

Takes care in personal hygiene Assistances in daily activities Implements caring activities Implements simple technical procedures Gives first aid for seizures, accidents and trauma. Defines the health status Resuscitates Assists nurse in nursing activities Procurements medicines

Works by guidance of home care nurse and follows the caring plan

Support by outdoors moving and ability to function

Personal care and activities in normal daily life First aid and pharmaceuticals assistance

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Knows ageing changes and the resulting personal needs and restriction of operational capacity. Knows physiology and functions in general (1 -2 years education program) Knows principles of personal care Knows standards of Hygiene (1 -2 years education program) Knows basic anatomy and physiology, relevant disease patterns Knows nursing aids Knows how to act in emergency situations

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Gives information and assistance in administrative matters, etc.

Gives information and assistance in administrative matters, etc.

Works by guidance of home care nurse and follows the caring plan

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ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

Communication

Knows interpersonal skills and techniques of communication and principles of communication in different situations. Knows the Code of Ethics.

Supports client and his/her family Uses communication skills based on win-win (such as contact taking-holding-finishing, active listening, clear self-expression and assertiveness skills). Is able to prevent conflicts and/or resolve them constructively. Makes work-related choices and decisions and solves problems. Communicates with customers and colleagues in a clientcentered way. Can act as a team-member and collaborate with other professionals and service providers.

Guides the client and his/her family Understands and responds to customer messages based on the specific client. Operates in a client-centered way while keeping the role of the service provider. Acts by ethical principles. Works as a team-member while respecting the principles of the work-group

HOME CARE NURSE/CARE WORKER (EQF4) ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

Household chores

Knows practical principles of household and cleaning

Has skills in household chores (cleaning, washing, taking care of

Organizes domestic work Gives information and assistance

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ROLE: content of the work/sets of activities

Support ability to function and activating client

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

Knows living environment of elderly people Knows income security Knows nutrition and healthy diet

clothes), procurement of food and shopping, other necessities and firewood or other fuel Notices a healthy diet and nutrition Organises safety living environments

in administrative matters, etc. Takes care of the environment, electrical and fire safety and, where necessary, knows how to protect himself/herself and the clients. Knows how to prevent accidents and injuries at work.

Knows ageing changes and the resulting personal needs and restriction of operational capacity. Knows physiology and functions in general.

Supports a person's by outdoors activities (by going to shop, bank etc. administrative matters)

Gives information and assistance in administrative matters, etc.

Knows physical and psychosocial changes of ageing

Has skills to utilize the clients' capacity and activate it, can create a cozy, aesthetical, and simulative environment (music, dancing, gymnastics, games, walking, memory, memory exercises, literary activities like reading etc., crafts, baking, everyday activities etc.).

Uses activating methods in the client work while considering other workers and the agenda.

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ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

Personal care and activities in normal daily life

Knows principles of personal care Knows standards of Hygiene Knows the most common diseases of different organ systems, influencing factors, and the main principles of care. Knows the care principles for a dying client. Takes advantage of the information on the work of the elderly, the physical and psychological illnesses and their treatment: the care of the mouth, skin, and feet; methods of physical activity and activity of physiotherapy; eating habits; nutrition and diabetes, pain treatments; memory disorders and their treatment; accident risks in the elderly first aid

Helps and guides in hygiene and dressing, considering clients' special problems (the care of the mouth, skin, and feet) Assistances in daily activities (supports continence, eating and drinking, respiration etc.) Implements caring activities

Works by guidance of home care nurse and follows the caring plan. With the support of the

First aid and pharmaceuticals assistance

Knows basic anatomy and physiology, relevant disease patterns Knows nursing aids Knows how to act in emergency situations Knows the main principles of

Notices the client's ability to cope, his/her habits, beliefs and life experiences, and notices the potential social problems as well as the needs of care services.

Is able to identify changes in the elderly client's health status and act accordingly. Is able to assist clients' living arrangements(care and nursing activities) Guides clients to use facilities and terotechnology Implements simple technical procedures Gives first aid for seizures, accidents and trauma. Defines the health status Resuscitates Assists nurse in nursing activities

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working group, draws / develops and updates the plan together with the client and their representative and implements and evaluates it. Is able to care for elderly clients while taking into account their life experience and the needs at the institution and in home care.

Can give first aid and resuscitation.

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ROLE: content of the work/sets of activities

Communication

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

medical care. Knows the effects and sideeffects of drugs, the most typical embedding, and the misuse symptoms

Procurements medicines

Knows interpersonal skills and techniques of communication and principles of communication in different situations. Knows the Code of Ethics, care-work regulating maintenance manuals, and legislative acts. Knows how to use maintenance manuals and legislative acts in elderly-work.

Supports client and his/her family Uses communication skills based on win-win (such as contact taking-holding-finishing, active listening, clear self-expression and assertiveness skills). Is able to prevent conflicts and/or resolve them constructively. Makes work-related choices and decisions and solves problems. Communicates with customers and colleagues in a clientcentered way. Can act as a team-member and collaborate with other professionals and service providers. Organises teamwork Supports colleagues, solves

Knows the management of social services.

Working in team

Knows the main principles of teamwork and how to use a

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COMPETENCE

Guides the client and his/her family, motivates and activates clients Understands and responds to customer messages based on the specific client. Operates in a client-centered way while keeping the role of the service provider. Acts by ethical principles. Works as a team-member while respecting the principles of the work-group

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ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE

variety of teams to support people.

problems Chooses a suitable communication form Delegates work

Works with elderly, children as well with people of special needs

18.2.1 References European Observatory on Health Systems and Policies, Health Care Systems in Transition, HiT Summary for Estonia, WHO Regional Office for Europe, http://www.who.dk/document/e85516sum.pdf#search='HiT%20summary%20AND%20Estonia' Kõre, J. (2005), Possibilities for integration of health and welfare services in Estonia in liberal political and economical circumstances, http://www.socialeurope.com/pdfs/Venice/presentations/kore.pdf# Merle Malvet, Pille Liimal and Kaja Vaabel (2005), Social care and welfare for the elderly and social services, http://www.parnu.ee/raulpage/welfa97.html#elderly Paat, Gerli and Merilain, Merle (2010). ISBN 978-94-6138-017-3 (http://www.ancien-longtermcare.eu/node/27) Social Welfare Act of 1995, http://www.legaltext.ee/text/en/X1043K6.htm Social Welfare Ministry (2005), Health and Long-term Care in Estonia: National report, April 2005, unpublished report. Social Welfare Ministry (2005), Developmental plan of Estonia’s nursing care network from 2004 to 2015, (http://www.sm.ee for Estonian version). Valdja, U. (2005), WHHO-Compendium Text (extract on the Estonia), http://www.nahc.org/WHHO/WHHOcomptext.html

http://www.alzheimer-europe.org/Policy-in-Practice2/Country-comparisons/Home-care/Estonia http://www.itk.ee/en/clinics/long-term-nursing-clinic/about-nursingclinic/long-term-nursing-center/home-care-service http://www.kutsekoda.ee/et/kutseregister/kutsestandardid/10558953 http://kutsekoda.ee/et/kutseregister/kutsestandardid/10559015/pdf/hooldustootaja-tase-4.10.et.pdf www.ubc.net_2966

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19 OLDER PERSONS HOMECARE IN FRANCE 19.1Introduction to older persons homecare service in France The population of France is 65.3 million, and over a quarter is aged 60 or older. By 2030, it is estimated that those over 60 will number some 20 million. The sharpest growth will be in the group aged 75 and above, which is expected to increase threefold. The 85+ group will be four times larger. These demographic changes will increase demand for elderly care facilities. (Morozova, 2015) Traditionally, it is natural among the French for senior relatives to be cared by their families. In accordance with the law, children are required to provide for their ageing parents. This, in particular, is the reason why old people's homes and retirement homes are less common in France than in other Western countries. Recently, however, this has gradually begun to change. A survey conducted by one of the country's leading sociological research centres, IPSOS, confirms that 90 percent of people aged 50 or older would prefer to live in their own homes as long as possible. A quarter of those over 85, though, are already in some form of assisted living, which amounts to around 450,000 people. In reality, it is not rare to see 85+ people in France: it has always been on the list of countries with the longest life expectancies. France invests more than most other European countries in health care, and the country's senior population benefits from this. The WHO ranked France's health care system as the best in the world depending on the fact that the French agree to "pay more to get more." Furthermore, the data indicate that care provided exclusively by household members constituted only onethird of the cases in France, that means that same household caregivers were more often than not reinforced by other sources of caregiving, whether formal, informal or both. The report shows that of all the French respondents who received any care, one-third received only informal care, about 40 percent received both formal and informal care, and one-quarter received only formal care. Historically, healthcare and social care services have been structured around large national non-profit associations of patients and their families. In France, these associations are grouped by type of care depending on the target users (people with motor disabilities, intellectual disabilities, sensory disabilities or mental health problems, senior care). As is the case for all private companies in France, all structures delivering home-care services as well as residential care services (except public employers) are controlled both by Labour Inspection (a government administration verifying that the labour legislation is adhered to) and the DGCCRF (General Director for Fair Trading, Consumer Affairs and Fraud Control, a government organization in charge of verifying the quality of goods and services provided to the public). There are many companies involved in home care. According to the National Agency for Personal Services (Agence Nationale des Services à la Personne), 11,600 different companies were providing care at the home of elderly people or people with disabilities in 2012. Some of these structures are part of one of the national federations of home-care organizations.

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The companies sending workers to the homes of people with disabilities (Sector 8810A – aide à domicile in the 2010 labour survey) are quite varied, but most have an associative structure. As a whole, 54% of the workers in this sector are employed by non-profit organizations (Association Loi De 1901), 11% work for a private company, 7% are employed by the public sector (mainly local authorities), 3% are employed directly by the households they work for and 2% are self-employed. Those employed either by an NGO or private company represent 22% of workers, but the employers’ legal status cannot be identified more precisely in the survey. In this survey, there were no employees in the home-care sector working for a cooperative company. A recent survey shows that French elderly people prefer to stay at home rather than in a residential care setting (Baromètre Prévoyance Dépendance 2011 TNS SOFRES). The fact that home care is cheaper than residential care has not greatly influenced the debate in France. In France, the sector of community-based home care matches a range of different issues, such as • • • • • •

home hospital services; home nursing services; helping people with disabilities get up, washed and dressed in the morning; household cleaning, cooking and shopping; helping them go for walks and attend leisure activities; assisting people with disabilities to travel

Recruitment intentions in home care services (home helpers – aide à domicile and aide-ménagère) were particularly high in 2012, with more than 50,000 forecasted recruitments; that means around one-third of the recruitments in the care sector. The recruitment of home care workers for elderly people is commonly directly managed by the household. Around 57% of the 891 million hours of care provided in personal services in 2010 was carried out by workers directly recruited by households (Ould Younes, 2012). Since 2005 Borloo plan has two goals: developing more jobs in the care sector and responding to social needs by establishing a long list of activities, mainly related to traditional home care for older people, that can provide tax reductions. In 2010, 1.46 million people were working in community care, including one million employed directly by households. In January 2006 the Universal Service Employment Cheque (Chèque Emploi Service Universel, CESU) was introduced, with the main objectives to promote the development of personal services, to reduce the use of undeclared staff in the domestic sector and to ease the recruitment and employment of home care personnel. The CESU was introduced to simplify the administrative work and to secure the payment of wages and social contributions for domestic workers. The cheques can be used for paying staff, who are directly recruited or for paying an organization that provides the domestic worker. Professionals involved in home care in France are: • •

employé à domicile/aide à domicile (home helper/home aid) (level 1), providing mainly IADL-related tasks; possibly having attained an ‘Assistant de Vie Familiale’ diploma. auxiliaire de vie sociale (home care assistant) (AVS) (level 2/3); additionally performing personal care services (same tasks as a nurse assistant, but not to people with disabilities linked to chronic illness).

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aide soignant (nurse assistant), providing help with IADL, and allowed to perform personal care but under nurse’s supervision, two years training leading to national diploma.

Services designed to maintain or restore individuals’ autonomy (primarily ADL (Activities of Daily Living) and IADL (Instrumental Activities of Daily Living) services) are legally defined at the state level. Education and training courses for any type of home-workers are defined jointly by the labour and health and social ministry and candidate may apply for at least 6 different types of qualifications, the most frequent being the AVS diploma. Still despite policies aiming at enhanced training programmes for home help and care sector, 75% of people working in SAD had no professional qualifications in 2005. The control on staff’s professional expertise is higher on non-profit agencies than on intermediate agencies (which only provide home workers to old persons). Education The education system for the care sector is mostly structured around two main trades of social workers: -

social assistants, mainly dedicated to providing information to people in need of care services specialized educators, directly in charge of delivering help and services.

Apart from social workers, home-care assistants (Auxiliaires de Vie Sociale) are low-skilled workers with low salaries and poor-quality, often part-time, jobs with lots of travelling from one client to another. The development of VAE (Professional Validation by Experience) is meant to improve the qualification level of these professionals, but the various obstacles encountered lead to a low success rate – around 2% of candidates acquire this certification. In a context of decreasing public resources, the care sector has to accept the need to make services more professional, ensure the quality of employment in the sector and increase the range of services to meet a broad, increasingly diversified range of demands. There is a discrepancy in the demand for improving the qualifications of the staff in this sector and the reduction of public subsidies to pay for the services. People with disabilities and older people have important needs, but their ability to pay more for the care they receive is limited. Financing Since 2002, benefits for seniors needing care have been provided through the so-called APA system (Allocation personnalisée à l'autonomie). The funds for these benefits originate from local councils and the newly created agency CNSA (Caisse Nationale de Solidarité pour l'Autonomie). The CNSA does not finance itself via tax credits. Rather it gathers funds from an extra working day of employees and by taking an additional 0.3 percent tax from employers, also claiming assistance from the existing healthcare budgeting system. The benefits are primarily intended for care for the elderly, but they also aim to give seniors a chance to maintain their independence for as long as possible. (Morozova, 2015)

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19.2HHCP involved in older persons homecare service in France: roles and competences EMPLOYÉ À DOMICILE/AIDE À DOMICILE (HOME HELPERS/HOME AIDS) (level 1); provide mainly IADL (Instrumental Activities of Daily Living) related tasks; possibly having attained an ‘Assistant de Vie Familiale’ diploma. Home-helpers are intended to provide assistance with everyday tasks to people aged 60 or more to enable them to carry on living in their own homes. The aim of home nursing care services is to prevent, postpone or shorten stays in hospital or residential care institutions. The Elderly Dependency Act of 20 July 2001 introduced the “allocation personalisée d’autonomie” (individual attendance allowance) known as APA. This allowance, paid to dependent people over the age of 60, is intended to cover the costs of any assistance they need due to the loss of their ability to care for themselves. They must also have their main residence in France and be dependent according to the AGGIR scale (Autonomie Gérontologique – Groupes IsoRessources). According to article L113-1 of the “Code de l’Action Sociale et des Familles”, any person over 65 without sufficient resources may benefit either from home help or a place in a private home or establishment. This home help may take the form of a payment or actual assistance with household tasks. Home help is partly financed by retirement schemes (depending on the income of the person receiving the service) and partly by social welfare benefits provided by the “département”. Certain services, such as meals-on-wheels and house alarm systems, are often financed by regional governments and recipients may have to contribute towards costs. Home nursing care services and other paramedical services, on the other hand, are fully financed by the healthcare system. Home care services for elderly people are mainly provided by private non-profit making associations and by municipalities. Many services are provided by volunteers and are therefore cost-free. People who need assistance (but to a lesser extent than that needed by people who are entitled to the individual attendance allowance) receive special allowances or increased benefits to pay for services from third parties (European Commission, 2002). The Law 2005-841 of 26 July 2005 on Personal Services and Social Cohesion introduced the “cheque emploi service universel” (CESU), which came into force on 1 January 2006. This replaces the “cheque emploi service” and the “titre emploi service”. CESUs can be purchased by individuals and used to pay directly for services required by an individual, including home help for elderly or disabled people, ironing, gardening and general housework. They can be for a predetermined amount or for an amount to be decided by the purchaser. They can also be co-financed by employers much in the same way as luncheon vouchers or holiday vouchers. Employers are entitled to a tax deduction (credit d’impôt) of 25% of their costs. It is also possible for other organisations to finance the CESU such as pension funds and insurance companies (webpublic.ac-dijon, 2005). The cheques can be purchased from any bank in collaboration with the national office for the collection of social contributions. People or organisations providing the services simply deposit the cheques into a bank account. The APA can take the form of services or cash and is paid irrespective of whether the person lives at home or in an institution. The allowance is for human and technical assistance, not the provision of care, which would be covered by health insurances. People in receipt of the APA can choose whether to pay for a service 562634-EPP-1-2015-IT-EPPKA2-SSA

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or to pay for a private person to provide the service (with the exception of spouses). A private person who is paid to provide a service must declare this as a salary. As of 1 January 2006, people with a monthly income of less than EUR 658.4 are not obliged to contribute towards the costs of the APA. People with an income higher than EUR 2,622.34 have to make a contribution of 90% of the costs. Those with incomes between these two amounts have to contribute progressively towards costs.

ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

ENVIRONMENTAL MONITORING

SKILLS

COMPETENCIES

know how to do - SKILLS as cognitive

know how to be

Knowledge of the basics of home environment safety

Reporting environmental risks (to whom, how, with what times)

Evaluating safety risks in home environment

Knowledge of the basics of hygiene in home environment (cleaning, food etc.)

Reporting hygiene risks (to whom, how, with what times)

Evaluating hygiene risks in home environment

Taking actions to reduce the risks

HEALTH MONITORING

EQUIPE WORKING

ADMINISTRATIVE SUPPORT

Knowledge of the main indicators of - physical risk conditions - mental health conditions

Reporting health risks (to whom, how, with what times) Taking actions to reduce the risks

Knowledge of the network of services which Addressing older adults to the main existing can support older adults at local level services which can improve their quality of life Activating formal and informal support to stimulate active and healthy lifestyle

Knowledge of the basics about the administrative practices related to aging

Evaluating (mental and physical) health risks in home environment

Evaluating the usefulness/necessity of activating a service Building a network around the older adult in collaboration with medical social workers, neighbors and volunteers

Supporting older adults in filling in tax return form and other administrative practices

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management Use of information technology tools Evaluating the purchase of the proper food according to economic availability and nutritional requirements

Knowledge of the basics of domestic economy Going shopping Knowledge of the basics of nutrition principles ACTIVITIES OF DAILY LIVING SUPPORT

Knowledge of the basics of physical and mental conditions of older adults Knowledge of the basics of socializing patterns

Accompanying older adult in the proper way when going out Promoting older adults participation in social activities relying on their network and/or expanding it

Promoting social activities

AUXILIAIRE DE VIE SOCIALE (AVS) (HOME CARE ASSISTANT) (level 2/3); additionally performing personal care services (same tasks as a nursing assistant, but not to people with disabilities linked to chronic illness). In March 2002, a national qualification called the Diplôme d’Etat d’auxiliaire de vie sociale (DEAVS) was introduced by decree in France. It specifically aims at improving the qualification levels of staff in the care service sector and at increasing the basic pay levels for qualified staff in the domestic care sector. The training is based on the idea that care service workers will be expected to carry out new tasks in the future, including taking care of increasingly fragile groups. Stress is placed on the ethical and deontological aspects of their jobs, as well as on the importance of working as part of a ‘care team’. The DEAVS is also intended to help care service workers access other types of training. The following principles must be respected when working as an AVS: 1. respect for the dignity, integrity, private life, privacy and safety of the person receiving care; 2. freedom of choice among the services offered; 3. customised provision of care and assistance that promotes development, independence and integration, and is adapted to age and needs; 4. confidentiality of information on the person receiving care; 5. access to information concerning the person receiving care; 6. information on the basic rights, the legal and contractual protection offered, as well as the possible legal remedies; and 7. participation in setting-up and implementing the plans to receive and assist the person. 562634-EPP-1-2015-IT-EPPKA2-SSA

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ROLE

KNOWLEDGE

SKILLS

COMPETENCIES know how to be

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

ENVIRONMENTAL MONITORING

Knowledge of home environment safety

Reporting environmental risks (to whom, how, with what times)

Evaluating safety risks in home environment

Knowledge of hygiene in home environment (cleaning, food etc.)

Reporting hygiene risks (to whom, how, with what times)

Evaluating hygiene risks in home environment

Taking action to reduce the risks HEALTH MONITORING

Knowledge of the main indicators of risk conditions for physical and mental health

Reporting health risks (to whom, how, with what times) Taking action to reduce the risks

Evaluating health (mental and physical) risks and difficulties in home environment

Knowledge of the ageing process Stimulating autonomous management of daily activities

EQUIPE WORKING

ADMINISTRATIVE SUPPORT

ACTIVITIES OF DAILY LIVING

Identifying the daily activities that can be autonomously performed by the older adults Knowledge of the network of services which can Addressing the older adults to the Evaluating the usefulness/ necessity support older adults at local level main services that can improve their of activating a service quality of life Knowledge of the communication strategies Activating formal and informal Creating the conditions to build a support to stimulate active and network around the older adult in healthy lifestyle collaboration with the GP, social workers, neighbours and volunteers Knowledge of the basics about the Supporting older adults in compiling administrative practices related to ageing fiscal practices and other management administrative practices Knowledge of the basics of nutritional principles

Going shopping

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SUPPORT

availability and food requirements Knowledge of the basics of domestic economy

Providing personal hygiene and personal care in general

Knowledge of the basics of physical and mental conditions of older adults

Supporting the older adult in the proper way when going out of home

Knowledge of the basics of social interaction

Supporting social interaction

Assessing the requirements and the abilities of the older adults

Promoting older adults social participation relying on his/her network and/or expanding it

AIDE SOIGNANT (Nurses’ aid, Nursing assistant, Care assistant, Healthcare worker). They are trained professionals, who support the nursing staff in hospitals, long-term care facilities, rehabilitation clinics, in doctor’s offices and in home care in providing basic care for patients under nurse’s supervision. The job can require ability to lift patients, great communication skills, and tolerance for clean up and care of patients who cannot fully care for themselves. Most nursing assistants, who may also be called healthcare workers, undergo training through programs offered by colleges, medical or technical schools, and through organizations like the Red Cross. Training is usually completed within a few weeks to a few months, depending upon the individual program, and classes are frequently taught by registered nurses (RNs). Most nursing assistant jobs require certification, which may be gained through participating in a class and passing examinations at the end. The certified nursing assistants assist in the basic human needs of the healthcare profession. They may help to bathe patients, feed them, change diapers or beds, empty bedpans, and help patients to bathroom or toileting facilities. They are also trained to take vital signs, which are measurements of pulse, blood pressure, and respiration, and are responsible for charting vital signs several times during each shift. The nursing assistant also needs to be fully aware of any significant change in a patient’s condition, and report it to the nursing staff. In facilities where patients are hospitalized for long periods of time, it is usually the nursing assistant, sometimes with the help of hospital orderlies, who helps patients turn over every couple of hours so they don’t develop bedsores. A nursing assistant may be the first responder when a patient calls for help, and the job can require some physical strength and knowledge of safe lifting tactics when patients who are ill or recovering need to get up to walk around, change their clothing, or get to the bathroom.

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Some nursing assistants may additionally support patients by helping them with prescribed physical or respiratory therapy exercises. In long term care facilities, nursing assistants can be trained to help exercise patients who are paralyzed or in a coma. These health care workers may also work with patients in home care settings, and may be the primary caretakers for patients recovering from conditions or who have long term disabling conditions.

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

ENVIRONMENTAL MONITORING

Knowledge of environment safety conditions

Reporting environmental risks

Evaluating safety requirements in home environment

Knowledge of hygiene factors (cleaning, food etc.)

Reporting hygiene risks

Evaluating hygiene requirements

Taking action to reduce the risks HEALTH MONITORING

Knowledge of the main vital signs of people with disabilities linked to chronic illness

Reporting changes in vital signs and patients’ conditions

Knowledge of the ageing process

Taking action to reduce risks depending on bad vital signs

Evaluating health (mental and physical) conditions and difficulties and changes in patients with disabilities linked to chronic illness

Stimulating autonomous management of daily activities

EQUIPE WORKING

Identifying the activities that can be autonomously performed by the older adults Knowledge of the local network of services Addressing the older adults to the Evaluating the usefulness/ necessity which can support older adults main services that can improve their of activating a service quality of life

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ADMINISTRATIVE SUPPORT ACTIVITIES OF DAILY LIVING SUPPORT

Knowledge of communication strategies

Activating formal and informal Collaborating with parents, GPs, support to stimulate active and social workers, neighbours and healthy lifestyle volunteers

Knowledge of the sanitary documentation related to ageing management

Supporting older adults in compiling sanitary documents and other administrative practices Helping with feeding

Knowledge of the basics of nutritional principles

Knowledge of the basics of domestic economy

Providing personal hygiene and personal care in general

Knowledge of the basics of physical and mental conditions of older adults

Supporting paralyzed and mentally and physically disabled older adults

Knowledge of the dynamics of social interaction

Supporting social interaction

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Evaluating the proper food to be bought on the basis of economic availability and food requirements Assessing the requirements and the abilities of the older adults

Promoting older adults social participation in social activities

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20 OLDER PERSONS HOMECARE IN GERMANY 20.1 Overview on the older persons homecare service in Germany In January 2016, the population of Germany was 81 269 958. In 2015 the natural increase was negative but due to external migration the population increased by 251 712.13. The population is expected to decrease to 74,512,858 until 205014. The population of very old persons (80+) is expected to increase from 5.4% to 13.4%. The life expectancies for men and women at age 65 are increasing from 17.4/20.6 years (EU-27: 17.2/20.7) in 2010 to 22.4/25.4 years (EU-27: 22.4/25.6) in 206015. (Table 34)

Table 34: Background statistics of Germany (7-103)

There was 2,5 million people in need of care in Germany in 2013. 70 % of them (approximately 1,8 million) attended at home and 30 % (0,75 million) will stay in residential care homes for older people. From total 1,8 million people attended at home 47 % were cared by relatives and just 23 % in cooperation via ambulant care

13

http://countrymeters.info/en/Germany http://www.worldometers.info/world-population/germany-population/ 15 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 95. 14

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Deliverable 2.1 services. There was 12 300 ambulant care services with 300000 employees and 12349 home care providers.16 In home care, 63% of providers were private-for-profit, 36% private-not-for-profit and 1% public17. Estimates of the number of LTC dependent older persons in 2030 ranges from 3.17 to 3.37 million to around 4.4 million to 205018. The home care is regulated by following laws and regulations: The long-term care insurance law (SGB XI) offers a general regulation of quality management and quality assurance. Medical Service of the Health Insurance Institutions in in charge on the local or regional level by controlling of the quality rules and monitoring according to a treaty that has been agreed upon by all partners involved: the LTCI-institutions, representatives of care providers on the federal level, and finally, regional providers of social subsidy.19 Germany is one of the few countries what offer social protection for LTC. The social and private long-term care insurance (LTCI, 1995) is a compulsory insurance to cover a portion of longterm care nursing costs. All persons insured by social health insurance funds are automatically assigned by LTCI funds and are insured by private health insurance companies to a private LTCI.20 The new Pflege-Weiterentwicklungsgesetz (care extension law) introduces a gradual increase of benefits for home care. The Act to Reorient the Long-term Care Insurance 2012 ("Pflege-Neuausrichtungs-Gesetz" - PNG), improved a number of benefits of respite care and short-term residential care for persons receiving care allowance. The PNG strengthened care allowance and home care by raising supplementary benefits for people with dementia or rather and introducing “domestic support” (for example to communication, keeping up an adequate day structure or activities for maintaining social contacts in or near the domestic environment) as a new category of home care in kind.21 Legislation to strengthen the Long-term care system ("Pflegestärkungsgesetze") 2014 – 2015, will implement major elements of strengthening the long-term care insurance as envisaged in the Coalition Agreement.22 There are three different arrangements receiving a recipient LTC23: care allowance (informal care) giving at home by close relative; home care (in kind) - a professional care provider (paid by LTCI) visits the recipient regularly at home residential care - either short-term or long-term stay in a nursing home. The LTCI distinguishes between three levels of increasingly severe care needs: Level I: extensive care of at least 90 minutes per day; Level II (severe care): need of at least 180 minutes of care per day; Level III (most severe care): need at least 300 minutes of care per day. Medical Review Board of the Statutory Health Insurance Funds (MDK) for the social LTCI and an equivalent body for the private LTCI will assess the need for care formally. People with dementia, mental handicaps or comparable mental-health problems can receive additional support, regardless of the care level assessed. The beneficiary is supposed to be in need for care at least for six months. There are different prices of services on different level and, thus, the person in need of care has to bear the difference.24 Care coordination has for long been a major issue in LTC provision: every person in need of care obtained a legal claim to help and support through a long-term care counselor.

16

Nowack – Boldajipour, 2013. ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 96. 18 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 95. 17

19

http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf, 113.

20

ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 95. 21 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 99–100. 22 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 100–101. 23 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 96. 24 ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 96.

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The attractiveness of the job of a HHCP is discussed broadly. There is the current and expected lack of qualified nurses and difficulties in finding qualified personnel in Germany. Immigration of qualified nurses from outside Europe is promoted. The government is working on new regulations for the three-year vocational training for nurses and nursing courses are expected to be introduced on an academic level. There is planned to merge three separate vocational educations (nurses for the elderly, nurses for children and nurses for acute-care of adults) in one general vocational training for nurses in order to enhance attractiveness and to broaden job perspectives.25 The geriatric infrastructure within the health care sector is still not well developed. Many long-term care facilities provide services of low quality. Family care was and is very important in Germany so also nowadays many elderly people are expecting to be cared for by their children, if care should become necessary. Currently, the majority of people in need of care receive either a care allowance or home care in kind, from family members, either spouses or children, between the ages of 50 to 65 years. The following professions belong to staff members in the home care agencies:26 • 33% are fully qualified nurses • 19% are fully qualified nurses for the aged (Altenpfleger) • 4.3% are aids of the fully qualified nurses • 2.9% are aids of the fully qualified nurses for the aged. The remaining staff represents different professions such as family care and social work, with 6.4% in vocational training. Mostly formal home care workers are so called nurse/carer for older people ‘Altenpfleger’ (EQF4) and careworker for older people ‘Altenpflegehelfer’ (EQF3). There is clear specialist deficiency in home care: - right now there needed already more specialists/ skilled workers - until 2030 need up to 500.000 additional care workers - the number of persons in need of care will increase up to 50% or more (Quelle: Pflegereport 2030 der Bertelsmann-Stiftung) - the number of young professionals decreases - lack of future senior/executive staff Levels of home care staff in Germany27: • Level 1 takes responsibility for delegated daily routine attendance • Level 2 lower than Assistance (for example Services under instruction) takes responsibility for delegated personal assistance • Level 3 Assistance of the skilled worker takes responsibility for delegated tasks in care • Level 4 skilled worker takes responsibility for controlling individual care processes • Level 5 takes responsibility for groups of clients with special needs • Level 6 takes responsibility for groups of clients with complex tasks, and team leader • Level 7 takes responsibility for leading the institution • Level 8 takes responsibility for control of scientific functions The regulations and procedures of vocational elderly care training (Altenpflegehilfe) vary in the individual German states. There was implementing of the reform in Germany merging of nursing education and training for geriatric care to a generalized care training, called nurses/health care professionals (Gesundheits- und Krankenpfleger). The new nurse/health care professional generalised people with receipt of unemployment benefit (SGB II/III) for exapmple immigrants without qualifikation and apprentices in initial vocational training from lower secondary schools who are interested in care.28 25

ec.europa.eu/health/ageing/docs/ev_20140618_co04_en. 2014: 98.

26

http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf, 115.

27

Nowack – Boldajipour, 2013. Nowack – Boldajipour, 2013.

28

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The reform of education to caring professions was needed because - the requirements of the qualification changes (multimorbidity, very old people etc.); - differentiation according to age groups is not anymore the current state of the nursing science; - it was necessary to raise the attractiveness of the qualification. The new reform of vocational care training, over 3 years ,with access from intermediate secondary school (MSA) and new academic care training over 4 years in university.

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20.2HHCP involved in older persons homecare service in Germany: roles and competences CARE WORKER Altenpflegehelfer (EQF3) ROLE (SET OF ACTIVITIES)

HOUSEHOLD CHORES

KNOWLEDGE know what - theoretical and/or factual knowledge

SKILLS know how to do - SKILLS as cognitive

COMPETENCIES know how to be

Knows practical principles of household and cleaning Knows living environment of elderly people Knows income security Knows nutrition and healthy diet

Has skills in household chores (cleaning, washing, taking care of clothes), procurement of food and shopping, other necessities and firewood or other fuel Notices a healthy diet and nutrition

Organizes domestic work Cooks

Knows ageing changes and the resulting personal needs and restriction of operational capacity. Knows physiology and functions in general (1 -2 years education program) (1 -2 years education program) Knows principles of personal care

Supports a person's by outdoors activities (by going to shop, bank etc. administrative matters)

Gives information and assistance in administrative matters, etc.

Assistances in daily activities

Implements daily activities

FIRST AID AND PHARMACEUTICALS ASSISTANCE

(1 -2 years education program) Knows basic anatomy and physiology Knows nursing aids Knows how to act in emergency situations

Implements simple technical procedures Resuscitates

Works by guidance of home care nurse

COMMUNICATION

Knows interpersonal skills and techniques of communication and principles of communication in different situations. Knows the Code of Ethics.

Supports client and his/her family Uses communication skills based on win-win (such as contact takingholding-finishing, active listening,

Guides the client and his/her family Understands and responds to customer messages based on

SUPPORT BY OUTDOORS MOVING AND ABILITY TO FUNCTION

PERSONAL CARE AND ACTIVITIES IN NORMAL DAILY LIFE

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Gives information and assistance in administrative matters, etc.

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clear self-expression and assertiveness skills). Is able to prevent conflicts and/or resolve them constructively. Makes work-related choices and decisions and solves problems. Communicates with customers and colleagues in a client-centred way.

the specific client. Operates in a client-centred way while keeping the role of the service provider. Acts by ethical principles. Works as a team-member while

HOME CARE NURSE/CARE WORKER ‘Altenpfleger’ (EQF4) ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge Knows practical principles of household and cleaning Knows living environment of elderly people Knows income security Knows nutrition and healthy diet

know how to do - SKILLS as cognitive Has skills in household chores (cleaning, washing, taking care of clothes), procurement of food and shopping, other necessities and firewood or other fuel Notices a healthy diet and nutrition Organises safety living environments

Organizes domestic work Gives information and assistance in administrative matters, etc. Takes care of the environment, electrical and fire safety and, where necessary, knows how to protect himself/herself and the clients. Knows how to prevent accidents and injuries at work.

Knows ageing changes and the resulting personal needs and restriction of operational capacity. Knows physiology and functions in general. Knows physical and psychosocial changes of ageing

Supports a person's by outdoors activities (by going to shop, bank etc. administrative matters)

Gives information and assistance in administrative matters, etc. Uses activating methods in the client work while considering other workers and the agenda. Activity-oriented and exemplary conception

HOUSEHOLD CHORES

SUPPORT ABILITY TO FUNCTION AND ACTIVATING CLIENT

SKILLS

COMPETENCIES

Has skills to utilise the clients' capacity and activate it, can create a cosy, aesthetical, and simulative environment (music, dancing, gymnastics, games, walking,

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memory, memory exercises, literary activities like reading etc., crafts, baking, everyday activities etc.).

PERSONAL CARE AND ACTIVITIES IN NORMAL DAILY LIFE

Knows principles of personal care Knows standards of Hygiene Knows the most common diseases of different organ systems, influencing factors, and the main principles of care. Knows the care principles for a dying client. Takes advantage of the information on the work of the elderly, the physical and psychological illnesses and their treatment: the care of the mouth, skin, and feet; methods of physical activity and activity of physiotherapy; eating habits; nutrition and dieabetes, pain treatments; memory disorders and their treatment; accident risks in the elderly first aid

FIRST AID

Knows basic anatomy and physiology, relevant disease patterns Knows nursing aids Knows how to act in emergency situations

COMMUNICATION

Knows interpersonal skills and techniques of communication and principles of communication in different situations.

Can assess, plan, and act with clients with different operational capacity in groups and individually. Helps and guides in hygiene and dressing, considering clients' special problems (the care of the mouth, skin, and feet) Assistances in daily activities (supports continence, eating and drinking, respiration etc.) Implements caring activities Notices the client's ability to cope, his/her habits, beliefs and life experiences, and notices the potential social problems as well as the needs of care services. Is able to identify changes in the elderly client's health status and act accordingly. Is able to assist clients' living arrangements(care and nursing activities) Guides clients to use facilities and gerotechnology Implements simple technical procedures Gives first aid for seizures, accidents and trauma. Defines the health status Resuscitates Assists in nursing activities Supports client and his/her family Uses communication skills based on winwin (such as contact taking-holding-

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Works by guidance of home care nurse and follows the caring plan. With the support of the working group, draws / develops and updates the plan together with the client and their representative and implements and evaluates it. Is able to care for elderly clients while taking into account their life experience and the needs at the institution and in home care. Can give first aid and resuscitation.

With the support of the working group

Guides the client and his/her family, motivates and activates clients Understands and responds to customer

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Knows the Code of Ethics, care-work regulating maintenance manuals, and legislative acts. Knows how to use maintenance manuals and legislative acts in elderly-work. Knows the management of social services.

WORKING IN TEAM

Knows the main principles of teamwork and how to use a variety of teams to support people.

finishing, active listening, clear selfexpression and assertiveness skills). Is able to prevent conflicts and/or resolve them constructively. Makes work-related choices and decisions and solves problems. Communicates with customers and colleagues in a client-centred way. Can act as a team-member and collaborate with other professionals and service providers. Organises teamwork Supports colleagues, solves problems Chooses a suitable communication form Delegates work

messages based on the specific client. Operates in a client-centred way while keeping the role of the service provider. Acts by ethical principles. Works as a team-member while respecting the principles of the workgroup

Organises, advices and leads team Works with elderly, children as well with people of special needs

20.2.1 References Adequate social protection for long-term care needs in an ageing society. Report jointly prepared by the Social Protection Committee and the European Commission services. Council of the European Union. Brussels 2014. ec.europa.eu/health/ageing/docs/ev_20140618_co04_en.pdf Home Care across Europe Case studies 2013. http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf Nowack Sabine G. – Boldajipour, Sigried. BACKGOUND RESEARCH and Vocational Education in the field of Elderly Care in Germany and Bremen. 2013. PP presentation in ECVET for Elderly Care seminar.

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21 OLDER PERSONS HOMECARE IN GREECE 21.1Overview on the older persons homecare service in Greece 21.1.1 The context of home care Greece’s population is one of the most old of the EU countries; the over 65 aged population in 20008 was 18,6% (average in EU27 17%) and will increase until 2030 becoming the proportion of over 80 more than double (Eurostat 2008). Moreover due to the distribution of the Greek territories, where there are islands and mountains, home care is often fragmented and difficult to implement. The healthy trends of population show that only 20.7% of Greek males and 24.5% of Greek female reported having longstanding disease or health problems, compared with 29.4% of males and 33.5% of females for EU27 (Eurostat 2010), The setting of healthcare in general and of homecare need to take into consideration also some social issues such as: an high level risk of poverty for elderly (in 2008 22%, Eurostat, 29-01- 2010) and pension replacement rate. In Greece the percentage of GDP spent on care for older adults is very low compared with the average of the EU27, less than one fifth (Eurostat, 12-02-2009). The law that governing the home care , delivered in 2001 and then reviewed in 2009, designed in detail the beneficiaries of the services (inclusion social and domestic care), the activities to be conducted and the professionals involved. The demand of home care is rapidly increasing and the budget seems to become too limited for the total amount of demands. The health care sector is mainly, more than 75% of the total costs, financed by national taxation and EU founding. Payment based on social insurance funds or private one are not allowed by publicly funded homecare. There are private homecare providers that provides services non reimbursable but some supplementary services (physiotherapy) can be partially funded through social insurance funds. The main actors involved in the home care delivery are: Ministry of Health and Social Solidarity( responsible for regulation of the services) Ministry of Employment (responsible for founding a part of the care services) Central body of the Local Authorities (KEDKE) (responsible for assessing the founding to home care services); Municipalities and Local Authority (responsible for providing social home aid through social enterprises and management of Open care centers –KAPI that provide health home care). Included in the home care setting, but in a marginal role, can be considered also NGO and Social insurance funds, responsible respectively of providing home care services for members and founding supplementary home care services. The services public founded are reserved for people who fulfil the requirements defined by Law: dependent, without caregivers and with low income, need the be supported to live independently.

21.2HHCP involved in older persons homecare service in Greece: roles and competences Despite the lacks of statistical data on HHCP, it’s estimated that there are around 120000 people working in homecare sector, not only with older adults. Most of them are employed by Agencies and partially work privately. There is a huge amount of specialized doctors, but indications from Hellenic Ministry of Health seems show the lack of nurses and GP (who are far below the European average in the number of

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professionals per inhabitant). Most of the employers in homecare sector, especially for older adults are undeclared workers, often immigrants, women, middle aged. The system, introduced in 2009, regulating the homecare services provide a detailed description of activities and tasks and time included in the Homecare services. Despite this national guidelines there are several differences depending on the Local Governments, founding availabilities and professionals. The education levels are defined by law on homecare in detail for the three main categories’ of professions involved in homecare service delivery (Table 35): Social workers, specialized in need assessment and coordination of the other professionals during the intervention; Nurses, professionals providing basic health care intervention, and home helps and support in daily living.

“Social Care” / “Help at Home” programmes Centers for Daily Care for the Elderly (KIFI) Social Scientist: Social worker Psychologist Sociologist Nurse Home helper Doctor Nurse assistant Physiotherapist Occupational therapist Administrative staff

Nurse Social service care taker Home helper

Table 35: “Social Care” / “Help at Home” programmes and Centers for Daily Care for the Elderly (KIFI)

The levels of education required to perform homecare services are defined by law and supported by professional unions. For social workers, physiotherapist, Occupational therapist and nurses the levels required is normally university degree, instead for home help is mandatory secondary education or equivalent. despite the definition of the levels of education required most a large portion of workers in homecare with older adults have no receive vocational training. There are no specific educational requirement for work with older adults. Leonardo Da Vinci Programme financed in 2008 the EU project ECVC “Elderly Care Vocational Certificate”, to create a system of vocational training to provide the participant an ECVC “Elderly Care Vocational Certificate” The Elderly Care Vocational Certificate empowers learners with theoretical knowledge enriched with practical experience on the following subjects: Vocational awareness; Basic ageing pathology; Environmental care; Basic body care; Hygiene; Nursing; Handling incontinence; First aids; Physiotherapy; Mobility and entertainment; Tools and materials The Hellenic Agency for Local Development and Local Government suggest, in addition to the competences of the specific profession, that the homecare workers should have obtained also the following transversal competences and skills: Social characteristics (patience, kindness, etc), Organizational skills (especially for social scientists, responsible for the coordination and operation of the unit) Communication skills, Ability to understand the seriousness of situations

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21.3HHCP involved in older persons homecare service in Greece: roles and competences SOCIAL SCIENTIST / SOCIAL SERVICE CARE TAKER ROLE / OCCUPATION

KNOWLEDGE

SKILLS

COMPETENCIES

to know the main indicators of risk conditions health and needs of older adults

information, recording / assessment of his needs

to evaluate an health need in home environment

to know the network of services which can support older adults at local level

forward of needs to appropriate services

to evaluate the usefulness / necessity of activating a service

Management and coordination skills

coordinating the other staff, scheduling the visits,

Collaborate with other professionals for the design and implementation of coordinated measures

to know the network of services which can support older adults at local level

cooperating with other local/public agencies)

to know the network of services which can support older adults at local level

Mediate to Public Services on behalf of the beneficiary

Know the basics of hygiene and preventive sciences for understanding the determinants of health, risk factors, prevention strategies, both individual and collective, and interventions aimed at promoting the health and safety of their users

informing the family for the services provided

HEALTH MONITORING

ORGANIZATION / COORDINATION DUTIES

SUPPORTING THE BENEFICIARY’S FAMILY

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NURSE: ROLE / OCCUPATION

KNOWLEDGE

PREVENTION

Know the basics of hygiene and preventive sciences for understanding the determinants of health, risk factors, prevention strategies, both individual and collective, and interventions aimed at promoting the health and safety of their users

NURSING CARE

SKILLS Tanking action to intervene in personal hygiene

COMPETENCIES Evaluating an hygiene risk

To educate people in healthy lifestyles and change those at risk

Knowing the biological phenomena of the main operating mechanisms the organs and apparatus, inheritance, and physiological phenomena, also in correlation with the psychological, social and environmental health and disease.

Implement nursing care by Take decisions nursing care intervention; customizing the choices based on similarities and differences between people assisted compared to values, ethnicities and socio-cultural practices;

Knowing the basics of physiology and pathology applicable to different environmental and clinical situations of the person

Establish with technical and structured and systematic manner the client's care problems through the identification of alterations in functional models

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Critically evaluate the outcomes of the care decisions made on the basis of the person's answers and care standards

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HEALTHCARE EDUCATION

Know the main nursing care needs of the elderly person

Identify the needs of nursing care of the elderly person

Prioritize interventions based on care needs, organizational needs and optimal utilization of available resources;

Know the theories of learning and change for the understanding of educational processes for citizens or patients;

“Training” person of the family who cares the old man, to basic daily activities

Supporting the beneficiary’s family

HOMECARE ASSISTANT / HOME HELPER: ROLE / OCCUPATION PREVENTION

ACTIVITIES OF DAILY LIVING SUPPORT

KNOWLEDGE

SKILLS

Know the basics of hygiene and preventive sciences for understanding the determinants of health, risk factors, prevention strategies, both individual and collective, and interventions aimed at promoting the health and safety of their users

House cleaning

to know the basics of nutrition principles

preparing food

COMPETENCIES

Personal hygiene

to know the basics of food preparation to know the basics of domestic

Going to market (purchase of food

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economy

and medicines)

to know the basics of nutrition principles

NURSE ASSISTANT ROLE / OCCUPATION

KNOWLEDGE

SKILLS

NURSING CARE

Knowing the biological phenomena of the main operating mechanisms the organs and apparatus, inheritance, and physiological phenomena, also in correlation with the psychological, social and environmental health and disease.

Basic nursing interventions (blood pressure, vaccines, etc)

PERSONAL CARE

Know the basics of hygiene and preventive sciences for understanding the determinants of health, risk factors, prevention strategies, both individual and collective, and interventions aimed at promoting the health and safety of their users

Assist for personal care (personal hygiene)

HEALTHCARE EDUCATION

Know the theories of learning and change for the understanding of educational processes for citizens or patients

Training” the person of the family who cares for the elderly to perform basic daily activities

COMPETENCIES

Supporting the beneficiary’s family

Supporting the beneficiary’s family

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PHYSIOTHERAPIST ROLE / OCCUPATION

PHYSIOTHERAPIC INTERVENTIONS

KNOWLEDGE

SKILLS

COMPETENCIES

Knowing the biological phenomena of the main operating mechanisms the organs and apparatus, inheritance, and physiological phenomena, also in correlation with the psychological, social and environmental health and disease

Establish with technical and structured and systematic manner the client's care problems through the identification of alterations in functional models

Critically evaluate the outcomes of the care decisions made on the basis of the person's answers and care standards

Implementing the assistance physiotherapy customizing choices on the basis of similarities and differences between people assisted with respect to values, ethnicities and socio-cultural practices;

To plan appropriate care interventions that take into account the values and guidelines of the people

Training person of the family who care the old men

using appropriate communication modes with the caregiver

Know the theories of learning and change for the understanding of educational processes for citizens or patients; HEALTHCARE EDUCATION

PREVENTION

Know the elements of psycho-social sciences and humanities for the understanding of normal and pathological relationship dynamics Basic knowledge of safety in home environment

Assessing “operational” and safety parameters of the beneficiary’s home

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OCCUPATIONAL THERAPIST: ROLE / OCCUPATION

OCCUPATIONAL THERAPY INTERVENTIONS

PREVENTION AND PROMOTION OF HEALTHY LIFESTYLE

KNOWLEDGE

Knowing the biological phenomena of the main functional mechanisms of functioning and psychological well with the social and environmental dimensions of health and disease

Basic knowledge of safety in home environment

SKILLS

COMPETENCIES

make a practical and psychological evaluation of the subject and elaborates, in multidisciplinary teams, the definition of the rehabilitation program, aimed at identifying the needs of the disabled person and his goodwill towards personal autonomy in the environment of everyday life and in

use both individual and group activities, promoting recovery and optimal use of functions aimed at reintegration, adaptation and integration of the individual in their personal, domestic and social; Assessing “operational” and safety parameters of the beneficiary’s home proposes, as necessary, changes to the living environment and promotes educational activities at the subject being treated, to the family and the community

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22 OLDER PERSONS HOMECARE IN HUNGARY 22.1Overview on the older persons homecare service in Hungary Hungary is a Central- European country with 10 million habitants. The socio-demographic context in Hungary is characterized by population ageing and a general decrease in the population size. The population over 65 and 80 are currently 17% and 4% respectively. It has an insurance-based public health care system funded by income-related social health insurance contribution. In Hungary, long- term care patients can receive services both from the health and the social care systems. The health care system operates under de National Health Insurance, while the social care system is managed at a local level. The central government is responsible for the health care legislation, as well as the financing for Long-term care. The local governments assume primary responsibly for organizing and delivering social care, which includes home care and nursing care, under the framework set out by the central governments. Home care as defined in Hungary includes: -

-

-

Domestic care: Basic social service provided to persons being unable to care for themselves in their home as well as to psychiatric patients, disabled persons and addicts who due to their condition, need help in performing the tasks necessary for independent life. Club for the aged: provides day care for elderly people who are partially capable of looking after themselves and in need of social and mental support, and enables them to maintain social relations, satisfy basic hygienic needs and to get daytime meals upon request. Day home for disabled: enables disabled or autistic person o over three years of age living in their own homes and not needing supervisions to find daytime shelter, maintain social relations and satisfy basic hygienic needs and to get daytime meals upon request.

The health care systems provides a primary medical assistances, operates a domestic medical nursing service for limited number of visits, and provides continuous outpatients special care for different type of chronically ill patients. Institutional care is only provided to individuals who require more than 4 hours of help per day. Individuals in need of 2 to 4 hours of care receive home care services, while those who require less than 2 hours of care per day receive no public assistance. Benefits are set at a national level but are often supplemented by additional benefits provided by local authorities.

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22.2HHCP involved in older persons homecare service in Hungary: roles and competences SOCIAL SCIENTIST / SOCIAL SERVICE CARE TAKER ROLE / OCCUPATION

Perform basic tasks related to the care of assigned patients.

KNOWLEDGE

SKILLS

COMPETENCIES

To prepare the necessary means to different instrumental tests and laboratory and diagnostic and therapeutic interventions.

To assist in the conduct of laboratory test and instrumental.

To create an atmosphere of care insurance, treating materials and infectious instruments according to the rules

To store instruments, textiles and bandage that help care.

To know the material and instruments

CARE ASSISTANT ROLE / OCCUPATION

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COMPETENCIES

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Verbal and non-verbal techniques to communicate in the correct way with families and partners (medical terminology) TAKE CARE

knowledge of Physiology, pathophysiology and clinical during the conduct of their work. First aid knowledge Basic pharmacology knowledge

To communicate with patients, family members and other members of the Group's care.

To carry out the documentation of care realted to their work

to apply both the spoken and the written medical terminology.

To help sick people / healthy of different ages in their physiological needs.

To observe and interpret the symptoms of the patient, indicate what that differ from the physiological.

To help in movement, rest, food, hygiene, selection, maintenance of proper body temperature functions and ensure the level of oxygen necessary according to the State and the needs of the patient.

To carry out the work according to the basic principles of Psychology care and the ethics of care. To provide first aid care to people who have had an accident. To perform tasks related to the medication orally, cutaneous or mucous, as well as the administration of subcutaneous injection of insulin following the instructions above. -To apply the resources. And transmission of information. To help the nurses / doctors during diagnostic and therapeutic procedures.

To develop their skills continuously. To perform tasks related to the deceased. to perform and develop first aids techniques and knowledge in order to help in which it is necessary. To organize its work according to the principles of care processes To meet the standards of labour safety, fire protection and prevention of accidents during the conduct of their work. To assist in the conduct of laboratory test and instrumental.

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GERONTOLOGICAL NURSE ROLE

KNOWLEDGE

SKILLS

COMPENTENCIES

To perform basic care duties in institutions providing care for the elderly, based on the doctor´s diagnosis, according to nursing protocols as a member of a team or individually, among elderly people with chronic diseases.

-First aids knowledge.

- To provide first aid to the patients under their care.

- To perform helping tasks in the framework of hospital social work.

-Investigation and resources techniques.

- To apply clinical studies in the performance of the job. -To apply their communication studies appropriately with those in care and their relatives as well as their colleagues. - To compile an environmental study, establish and analyze a nursing anamnesis, apply social psychology, socio-cultural studies.

-To know healthy lifestyles and how to get them

-Geriatric special care.

- To perform health education work based on modern health pedagogy studies for the patients in their care and their relatives

- In welfare institutions providing help for the elderly, together with the nursing team perform special nursing jobs among the elderly suffering from diseases related to age, - To take part in hospice care.

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- To be update in the last care scientific progress and to apply those progress in the daily work.

-to promote a healthy life, trying to eliminate bad health habits as smoke, drink too much alcohol…

-To participate in the care of elderly people suffering from oncology diseases and in a terminal illness. -To help to organize the daily activities of the elderly, compile schedules for the activities of the elderly, compile a rehabilitation plan and provide help in their implementation.

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-To know verbal and non verbal techniques to the management of the aggressive patient -Bioethical, Legislative and administrative knowledge

- To help the elderly in a crisis situation or a deviant state to regain their mental balance. - To perform their work in accordance with ethical norms. -To provide for the storage, records of nursing and therapeutic tools, document their activities by using their IT knowledge. -To provide help in request for social benefits and allowances, to arrange administrative tasks, and represent the interests of the patients in their care. -To coordinate the work of the team performing the nursing tasks, establish relationships with non-governmental organizations for the sake of the patients under their supervision.

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23 OLDER PERSONS HOMECARE IN IRELAND 23.1Introduction to older persons homecare service in Ireland In Ireland the main government departments responsible of the home care for elderly people are: “Department for Health and Children”, “Department of Social and Family Affairs” and “the Department of Finance”. Caregivers dependent of these departments have developed a document in 2008 known a “Long Term Care Report” which reflects many of the objectives that have influenced the current policies of the home-based caregivers in the country. In practice, there is a dominant strategy of the “Health Service Executive (HSE)” which is recruiting a significant number of health professionals and social workers, in addition to volunteers and other workers. The following demographic statistics are from Ireland's Central Statistics Office (CSO), Eurostat and the CIA World Factbook. Population 65 years and over: 11.7% (male: 243,314; female: 292,079) Sex ratio a) 65 years and over: 0.8 male(s)/female b) total population: 0.99 male(s)/ Life expectancy at birthtotal population: 80.19 years a) male: 77.96 years b) female: 82.55 years When choosing the home-based caregivers there are a wide variety of criteria according to the different regions, due to the lack of a national standardisation. Home help and the personal care delivery is widespread in Ireland and is financed by the State and other Regional Institutions of the “Health Service Executive (HSE)” that allow an assistance funding through copayment for those elderly people who are not entitled to a health card. Family caretakers in Ireland are being recognized as a group of citizens with special rights. 60% of these family caretakers spend between 1-19 hours on caring responsibilities and 27% spend more than 50 hours per week caring for their relatives. Ireland, for its part, has had an important growth in the private sector in these type of services. The main difficulty at national level is in the low-wages, particularly for unskilled workers. Regarding nursing professionals, they follow university training with general knowledge about health, in the community and public health, providing primary health care; skills on health care organisation, leadership, 562634-EPP-1-2015-IT-EPPKA2-SSA

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evidence-based health and skills on professional and personal development, the influence of society concerning health issues, negotiating skills, knowing how to respect people and defend their dignity. Specialised training is only available in palliative care and dementia.

Figure 24 - Population in Ireland 2014

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23.2HHCP involved in older persons homecare service in Ireland: roles and competences NURSES Role/ Occupation

EQF

Knowledge

Skills

know what - theoretical and/or factual

know how to do - SKILLS as cognitive and

knowledge

practical

○ Concepts of health, of community and ○

○ ○ ○ General cares

6

○ ○ ○ ○

of public health. Public health theory and practice at a National, European and International level Public health in community practice Primary health care Determinants of health: biological, behavioural, gender, social, environmental, economic, educational, political and cultural factors affecting health Infectious/communicable diseases, screening and surveillance Risk assessment, and measures of health Environmental health Professional values in the provision of public health - an understanding of the current climate and political influences

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Competences know how to be

○ Professional/Ethical ○ ○ ○ ○ Holistic Approaches to Care and the ○ ○ ○ ○ ○

Integration of Knowledge Organisation and Management of Care. Leadership skills Evidence based health care and information technology Strategic planning and forecasting Equity in health and health care

○

○ ○ ○

○

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Practice. Interpersonal Relationships. Personal and Professional Development. Influence of society on health Psychological theory and its application to public health nursing. Negotiation and influencing Nurses respect each person as a unique individual Nurses respect and defend the dignity of every stage of human life Nurses respect and maintain their own dignity and that of patients in their professional practice. They

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on health care, the values, priorities and contributions of health professionals. ○ Knowledge and skills for effective management.

believe that this respect is mutual with patients. ○ Nurses are expected to show high standards of professional behaviour. ○ Nurses are professionally responsible and accountable for their practice, attitudes and actions including inactions and omissions. ○ Nurses advocate for patients’ rights.

COMMUNITY NURSING ASSISTANTS

Role/ Occupation

Perform duties and tasks to facilitate our customers to live at home and in their communities in a safe, secure and comfortable way.

EQF

3-4

Knowledge

Skills

know what - theoretical and/or factual

know how to do - SKILLS as cognitive

knowledge

and practical

○ ○ ○ ○ ○ ○ ○ ○

Defining health and wellness Determinants of health Illness behaviour and the sick role Health promotion Defining rehabilitation The multidisciplinary team Rehabilitation nursing practice Pharmacology

○ Using Medical Terminology ○ Security Procedures

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○ Codes of Conduct ○ Confidentiality & Privacy

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HEALTH CARE ASSISTANTS

Role/ Occupation

EQF

Determined by staff who had completed the Health Care Assistant's course, staff undergoing the course and then seniority of staff.

3-4

Knowledge

Skills

know what - theoretical and/or factual

know how to do - SKILLS as cognitive and

knowledge

practical

○ Ensure dietary needs are adhered to,

○ Assisting residents with their hygiene needs,

including special diets and supplementary drinks under the direction of the nursing staff. ○ Recording care plans, vital signs and fluid balance. ○ Reporting to nursing staff any complaints of pain, distress etc. from clients

such as, bathing, hair care, shaving, dressing and undressing. Pressure area care. ○ Helping those who need help at meal times. ○ Cleaning and restocking of linen presses/wardrobes and ensure personal clothing is in the correct locker/wardrobe.

Competences know how to be

23.2.1 References International Career Institute. Nursing Assistant [Internet]. Retrieved from: http://ici.edu.au/courses/health-and-fitness/nursing-assistant/ Peppard L. Health Service Executive [Internet]. Retrieved from: http://www.hse.ie/eng/staff/jobs/profiles/careassistant.html Hillery M. Family Caring in Ireland [Internet]. Dublin: Care Alliance Ireland; 2013. Retrieved from: http://www.carealliance.ie/userfiles/file/Report 2013 FA 130513.pdf Management

competency

wheel

for

nurse

and

midwife

managers

[Internet].

Office

for.

Retrieved

from:

https://pnd.hseland.ie/download/pdf/nursecomps_complete.pdf Nursing and Midwifery Board of Ireland (2014) Code of Professional Conduct and Ethic for Registered Nurses and Registered Midwives Dublin, NMBI. Retrieved from: http://www.nmbi.ie/ECommerceSite/media/NMBI/Publications/Code-of-professional-Conduct-and-Ethics.pdf?ext=.pdf Nursing and Midwifery Board of Ireland (NMBI). Public Health Nursing Education Programme [Internet]. Ireland; 2014. Retrieved from: http://www.nmbi.ie/ECommerceSite/media/NMBI/Publications/public-health-nursing-education-programm-standards-requirements.pdf?ext=.pdf 562634-EPP-1-2015-IT-EPPKA2-SSA

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24 OLDER PERSONS HOMECARE IN LATVIA 24.1Introduction to older persons homecare service in Latvia In recent years the demand for social care services in Latvia has increased substantially. This trend can be explained by the ageing of society. According to the latest estimates of the Central Statistics Bureau, there were 2,248,374 residents in Latvia at the beginning of 2010. Among them, 390,209 were older than 65, while the remaining 1,858,165 were aged under 65. As of 1 January 2016, the population of Latvia was estimated to be 1 956 526 people. During 2016 Latvia population is projected to decreased by -23 126 people and reach 1 933 400 in the beginning of 2017. The number of deaths will exceed the number of live births by 8 980, so the natural increase is expected to be negative. If external migration will remain on the previous year level, the population will be declined by 14 146 due to the migration reasons. (http://countrymeters.info/en/Latvia.) Professionals at the University of Latvia Centre of Demography forecast a significant 20% drop in the number of residents to 1,872,855 until 2050, due to the decreasing birth rate (http://www.ancienlongtermcare.eu/sites/default/files/ENEPRI%20_ANCIEN_%20RR%20No%2081%20Latvia%20final.pdf). Therefore, an increase in elderly persons needing long-term social care is certain. 16,9 % from the total population are over 64 years old: from 331 612 persons 107 883 are males and 223 729 females. Total life expectancy (both sexes) at birth for Latvia is 72.7 years. (http://countrymeters.info/en/Latvia.) Latvia is one of the three Baltic countries which have similar political and economic development during 20th century. Latvia was re-established as a democratic state on 1918. It remained independent until the outset of World War II, when it was occupied by the Soviet Union for nearly 50 years. Since the declaration of Latvia’s independence in 1990, there have been a series of economic and social reforms leading to steady economic growth and stability. Latvia is divided into 118 administrative divisions, of which 109 are municipalities and 9 are cities. (https://en.wikipedia.org/wiki/Latvia.) Since regaining independence in 1990, Latvia’s path towards a structured social insurance system started in 1991 with the founding of the Ministry of Welfare. The ministry managed policy issues in social security, work, health and gender equality. There is no separate system for providing long-term care in Latvia and it is divided between the health and welfare systems (2003). The strategic aim of Latvia’s health and welfare systems is to provide mental, physical and social welfare as close as possible to clients’ homes. Social care services seek to maintain the existing quality of life of clients who are unable to sustain it themselves (para. 18, Law on Social Care and Social Assistance). The explicit target group of the long-term care system in Latvia is those over age 62, because currently people retire at that age. Long-term care in Latvia is managed on three levels: the state, municipality and social service provider. The first level involves the Ministry of Welfare and to some extent the Ministry of Health as well. They draft legislation, develop policies and standards, implement policies and monitor service providers as well keep the register of social services providers. At the second level, municipalities develop social service conceptions, proposals for the introduction of new services, perform research in the field and monitor social service providers. Social service workers assess client needs and resources, and provide services to clients. A client’s ability to pay for such services is assessed as well. The general problem that affects home care is the lack of social work professionals in Latvia. Increasing the number of educated social-work professionals has been among Latvia’s priorities since 2005. This situation has arisen because of the low salaries and disadvantaged working conditions in the field. At the end 2008, only 49% of all municipal social workers had an appropriate level of education in this field (Ilves–Plakane, 2011: 8). During the economic crisis of 2008–09, the policy centered on creating a social insurance net for those in severe financial need. Developing alternative social-care services is also part of the current policy debate. The main focus today, 562634-EPP-1-2015-IT-EPPKA2-SSA

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however, is on integrating the aged and the disabled into society, as well as on developing and implementing an improved quality control system for long-term care service providers. Care at home can be received by individuals who cannot take care of themselves because of old age, their state of health or functional impairments. Home care services are provided by either the municipal social services or by non-governmental or private organizations with which the municipality contracts. (para. 22, Law on Social Care and Social Assistance). Home nursing is a process where the health care services are performed by certified nurses’ or doctors’ assistants at the patients’ place of residence. The patient is provided with health care services at home if he needs a regular outpatient treatment, but he is not able to arrive to the medical institution to receive a treatment according to the medical indications. (http://www.nivel.nl/sites/default/files/bestanden/Home-careacross-Europe-case-studies.pdf.) The main welfare basis for regulating long-term care is the Law on Social Services and Social Care. The Law on Social Security outlines the basic principles for the social security system and specifies the key social rights and duties of benefit recipients. Cabinet Regulation No. 288 prescribes the procedure according to which residents can receive social care and Regulation No. 275 describes the organization of payment for social care. (Ilves–Plakane, 2011: 5.) The health care services provided by long-term care institutions and formal, home-based nursing care are regulated by the Law on Health Care, the Law on Patient’s Rights, Cabinet Regulations No. 60 on “Mandatory requirements for health care institutions and their branches”, No. 574 on “Regulations on hygienic and antiepidemic requirements for health care institutions” and No. 1046 on “Regulations for health care organizing and financing”. Lastly, the Law on Financing and Management of the Health Care System lists those health care services that are financed by the state. (Ilves–Plakane, 2011: 5.) The clients of long-term care services are asked to pay for the services they receive, but if they are unable to do so or if they can only pay a portion, the state takes over the payment. In general, the state and the municipalities are responsible for financing long-term care even if there are no client co-payments. Latvians are financially liable for their parents’ care costs and their ability to care is taken into account. One third of the population over 65 is at highest risk of poverty in Europe. Almost half of respondents answered that care should be provided by close relatives, even if it would affect their career. Home care provided by professionals is perceived less favorable, even compared to nursing home care. Asked about preferred options for their dependent elderly parents, only 10% mentioned professional home care. (http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europecase-studies.pdf) Activities of home care providers are limited by volume of health care budget. Home care is funded by national revenue including income and consumption tax revenue and for services outside the benefit package by private payments. Home help services are funded through the municipal budget and client co-payments. Privately hired services are paid completely out-of-pocket. Health care at home providers are generally paid per visit, irrespective of the service. Medication, such as injections provided during the visits, is paid per ‘doses’. In the price of public home health care (as health/medical care) visit are included salary, transport, basic medicine and medical goods and additional (indirect) costs. The prices of domestic aid and personal care are fixed per municipality and usually they do not covet transport costs. (http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europecase-studies.pdf) Peoples who need (social) home care can choose between private home care and social home care, depending on the number of providers available. For the patient it is cheaper to stay in an institution. There is a lack of both informal carers and formal carers in Latvia. Only municipalities having more than 3,000 inhabitants were obliged to have a social care office. Small municipalities are not obliged to organize social care. Especially in rural areas conditions for home care are poor. A ground for unmet needs is that clients can only have health care at home once a day. (http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf)

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Formal care makes up the vast proportion of long-term care services. There is an insignificantly small proportion of informal care in Latvia, and thus no data on it. The country’s economic situation discourages widespread informal care, such that families are not financially secure enough to leave jobs and take care of their relatives. In addition, no legislation focuses on informal care. Developing alternative social-care services has been the Ministry of Welfare’s priority. The first initiative is called “Safety button”, and has been launched by the Latvian Samaritan Association. It has an operations unit that is contactable 24 hours a day and which reacts to any health or household problems that an elderly person might experience at home. Other initiatives include a course on social care organized by Latvia’s Evangelistic Church and home health-care lectures by the nurses’ Care Service that are available to the clients’ families. Still, it is necessary to mention a problem that affects all kinds of care, which is the lack of social work professionals in Latvia. This situation has arisen because of the low salaries and disadvantaged working conditions in the field. (Ilves–Plakane, 2011: 8.) Home care is organized by the respective municipality’s social services. Either the municipal social services provide home care to its residents or it contracts with an NGO or private organization to provide such services. Of the 118 municipalities, the social services of only 30 provided home care themselves and 8 municipalities purchased home care either from NGOs or from private institutions during 2009. In the other 80 municipalities, home care services were not available. The share of municipalities without home care is large for two reasons. First, some local governments are unable to provide social services because of a lack financial and staff resources. Second, the low density of residents in some rural areas makes the supply of social care services cost ineffective. Furthermore, reaching isolated rural homes on unpaved roads can become impossible in autumn and winter; thus, it is safer to transfer these clients to long-term care institutions at once. Very often home-care clients receive additional services, such as a hot dinner and a ‘safety button’ service. The safety button offers the possibility to reach a relief service 24 hours per day and is provided by the NGO, the Samaritan Association. The Samaritan Association has signed a contract with the local governments of Riga, Rēzekne and Liepāja. Residents of other local government areas can purchase similar services individually. (Ilves–Plakane, 2011: 10.) There are following practitioners working in home care services in Latvia: carer, social carer, social worker and certified nurses or doctor’s assistans. Education is not required by carer, but they are usually trained by the provider; mainly providing personal care services. Social carer has two years education of mainly higher professional education providing personal care services and coordination. Social worker involved in coordination with other care providers and has four years degree obtained at any type of higher educational establishment. Certified nurses (three years education) or doctor’s assistants (three years education): providing medical care at home, informing and instructing clients and their families (http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf).

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24.2HHCP involved in older persons homecare service in Latvia: roles and competences SOCIAL CARER ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE in terms of responsibility and autonomy

PERSONAL CARE SERVICES AT HOME

two years of mainly higher professional education providing personal care services and coordination; two years of mainly higher professional education providing personal care services and coordination;

Proceeds personal care services

Gives information and assistance in administrative matters, etc. Advices carer

ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

Involved in coordination with other care providers;

four years degree obtained at any type of higher educational establishment; involved in coordination with other care providers; Knows interpersonal skills and techniques of communication and principles of communication in different situations.

COORDINATION

Organizes domestic work Coordinates work

SOCIAL WORKER

Communication

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Advising

Guides the client. Guides the other care providers

CERTIFIED NURSES OR DOCTOR’S ASSISTANTS ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE in terms of responsibility and autonomy

PROVIDING MEDICAL CARE AT HOME

(three years education) or (three years education): Knows medical care

Provides medical care

coordinates work together with other care providers

COMMUNICATION AND ADVISING

Knows interpersonal skills and techniques of communication and principles of communication in different situations.

Informs and instructs clients and their families, and supporting the GP when necessary.

Guides the client and his/her family Guides the other care providers

24.2.1 References Kaspar Ilves and Baiba Plakane:The Long-Term Care System for the Elderly in Latvia, 2011. ENEPRI RESEARCH REPORT NO. 81 MAY 2011 The long-term development guidelines for LTC policy were set by the National Development Council in 2010. The Sustainable Development Strategy of Latvia until 2030 (NDC, 201) http://www.ancien-longtermcare.eu/sites/default/files/ENEPRI%20_ANCIEN_%20RR%20No%2081%20Latvia%20final.pdf http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf http://projects.centralbaltic.eu/project/473-innocare http://innocare.edicypages.com/ http://countrymeters.info/en/Latvia https://en.wikipedia.org/wiki/Latvia 562634-EPP-1-2015-IT-EPPKA2-SSA

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25 OLDER PERSONS HOMECARE IN LITHUANIA 25.1Introduction to older persons homecare service in Lithuania As of 1 January 2016, the population of Lithuania was estimated to be 2 850 400 people. Since 1990 the number of births has been diminishing, the number of deaths has been growing and the population deceasing (forecast for 2030 is 21,). During 2016 Lithuania population is projected to decreased by -46 433 people and reach 2 803 967 in the beginning of 2017. The number of deaths will exceed the number of live births by 14 223, so the natural increase is expected to be negative. If external migration will remain on the previous year level, the population will be declined by 32 210 due to the migration reasons. It means that the number of people who leave Lithuania to settle permanently in another country (emigrants) will prevail over the number of people who move into the country (to which they are not native) in order to settle there as permanent residents (immigrants). The sex ratio of the total population was 0.867 (867 males per 1 000 females) which is lower than global sex ratio. 16,5 % from the population are older as 65 years. Total life expectancy (both sexes) at birth for Lithuania is 75.3 years. (http://countrymeters.info/en/Lithuania). The results of the European Commission’s survey on ageing (2009) indicate that life expectancy at birth will increase to 80 years for men and to almost 87 for women by 2060. It is foreseen that life expectancy at age 65 will increase to 20 additional years for men and almost 24 for women, which is below the average of the EU (the corresponding numbers are 21.8 for men and 25.1 for women). It is estimated that every third inhabitant of Lithuania will be an elderly person in 2050. Lithuania was re-established as a democratic state on 1918. It remained independent until the outset of World War II, when it was occupied by the Soviet Union for nearly 50 years. Since the declaration of Lithuania’s independence in March 1990, there have been a series of economic and social reforms leading to steady economic growth and stability. The Lithuanian health system is a mixed system, predominantly funded from the National Health Insurance Fund through a compulsory health insurance scheme, supplemented by substantial state contributions on behalf of the economically inactive population amounting to about half of its budget. Public financing of the health sector has gradually increased since 2004 to 5.2% of GDP in 2010. The state health-care system is intended to serve the entire population, and the Health Insurance Law requires all permanent residents and legally employed non-permanent residents to participate in the compulsory health insurance scheme (typically paying 6–9% of taxable income), without an option to opt-out. The 60 municipalities (varying in size from less than 5000 people to over 500 000) become responsible for organizing the provision of primary and social care, and for public health activities at the local level. The principal guidelines for the public health service have been outlined in the Health System Law (1994), Lithuanian Health Programme (1998–2010) and the National Public Health Strategy (2006–2013). Education for social and health care practitioners is organized in universities and colleges providing vocational training. There are also six colleges providing vocational training for nurses and other health-care personnel. According to the Government Resolution of 2003, current medical training programmes cover undergraduate and postgraduate levels: six years for the diploma (four years for public health, nursing, midwifery and rehabilitation) and three to six years for residency training programmes depending on specialty. A master’s degree in public health, nursing or rehabilitation can be obtained in two years. Non-university training programmes last from two to three and a half years. (Health Systems in Transition. Vol.13, Nr 2. 2013.) The social and health care services offered to the elderly are provided through three main sectors: health care, the social welfare system and the private sector together with non-governmental organizations. Long-term care is provided in two sectors: health and social care. There is a lack of distinction across the service provision, for which no unified legal arrangements have been created, nor is there a central or regional institution that regulates LTC service procedures. The long-term care services provided by the health care 562634-EPP-1-2015-IT-EPPKA2-SSA

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system and social services for dependent individuals (through social services), the latter of whom include the elderly. (http://www.ancienlongtermcare.eu/sites/default/files/ENEPRI%20_ANCIEN_%20RR%20No%2082%20Lithuania.pdf.) In response to the increasing need for nursing provision, regulations and additional payments from the NHIF were introduced in 2008 for nursing services at home provided by primary care nurses. Community primary health-care institutions have been in charge of nursing services in a patient’s home. Home care includes nursing and social care services, which are provided by various professionally trained workers at the home of the care recipients. These services are provided to those who are unable to live at home independently and who have partly lost their independence through old age or disability. Long-term social care services (from 2012) are provided mostly for elderly and disabled people in need of care, according to their ability to function independently. Social services development policy is guided by the Ministry of Social Security and Labour while municipalities are in charge of social services provision. Social services provided at home are mainly publicly funded but are subject to co-payments, depending on the age and disability status of the recipient as well as household income. (Health Systems in Transition. Vol.13, Nr 2. 2013.) In social care institutions, LTC is provided for those who are totally dependent and who need the permanent care of professionally trained caregivers. The eligibility criteria for long-term care are different for the health care and social sectors. Services by the social sector are provided to a person who is by reason of age, disability or social problems partially or completely lacks, or has not acquired or has lost the abilities or possibilities to independently care for his/her private (family) life and to participate in society. The eligibility criteria include the level of dependence, the need for services, and the income and property of the individual. Cash benefits are not means tested. The benefits are paid if persons defray. (http://www.ancienlongtermcare.eu/sites/default/files/ENEPRI%20_ANCIEN_%20RR%20No%2082%20Lithuania.pdf.) In Lithuania the demand and supply of informal care have not been regularly studied. The study of the need for nursing and social services in the Kaunas district by Hitaite and Spirgiene (2007) indicated that 69.7% of elderly persons who needed home nursing were cared for by family members, 10% were cared for by neighbours and 7.7% by community nurses; only 3.8% paid for this service. The supply of informal care is still high in Lithuania. Carers and social workers provide home-based LTC, which includes nursing, shopping and help at home. In 1997, more than 2,200 carers were involved in care provision throughout the country. This number has increased, but is undoubtedly still insufficient to meet the current need. Despite the support by (non-)governmental institutions, long-term care in the community remains an activity mainly carried out by families, neighbors, friends and volunteers. Unfortunately, there is no information available on the supply of long-term care at home. (http://www.ancienlongtermcare.eu/sites/default/files/ENEPRI%20_ANCIEN_%20RR%20No%2082%20Lithuania.pdf) Conclusion In Lithuania home care services are in developing point. There have been a series of economic and social reforms leading to steady economic growth and stability after 50 of occupation. The health and social care systems based on three traditions: - there is tradition to organize public care and nursing - elderly care based on hospitalization as cheaper and traditional way (long term care) - traditionally family, children and neighbors are responsible of elderly care, caring is not granted by government and carers are untrained. The practitioners in home care can be formal and informal worker: Home care services are provided by social workers and self-employed house cleaners; the latter is hired by family members. Educated community nurses as well Red Cross’ nurses (without special training) can participated in home care. Domestic aid is provided by volunteers too: Samaritans, Caritas’ volunteers and Student Volunteer Organization ‘Patrica’. Courses of one to

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two months in duration are organized for volunteers; courses are obligatory. Most frequently volunteers provide help with activities of daily living and not with nursing and medical support. Finland, Estonia and Lithuania participated in Erasmus + SSA project ECVET for Elderly Care (2013 – 2014). During this project Lithuania would like to influence to image of elderly care sector and develop a new curricula for care worker. However, there was not discussion about the current situation of home care or developing of home care. Gathering information about home care sector was difficult and based only on literature revue. Unfortunately contact persons did not answers to different contacts. By background literature there is challenges of human resources issues in Lithuania and the availability of trained health-care workers and migration. The issue of health worker migration has been the subject of broad debate in Lithuania, particularly since joining the EU in 2004. A study conducted in 2006 showed that the main drivers for emigration among health and social care workers were low wages, excessive workload, poor working arrangements and unsatisfactory work environment (Health Systems in Transition. Vol.13, Nr 2. 2013). The current plans of the Ministry of Health are as follows: • To accelerate development of nursing at home, integration of nursing and care; • To assign several community nurses to a family doctor; • To allocate more social workers, especially in rural areas; • To expand rehabilitation services at home; • To develop day-stay services; • To increase the extent of personal health care services at home; • To establish units at nursing hospitals for palliative care at home; • To improve the financing for nursing care at home; • To decentralize personal health care institutions in order to improve access to the services; • To give a special attention to medical care services in rural areas; • To increase financing, to promote preventive measures, to improve the quality of nursing; • To develop long-term monitoring system for patients with chronic diseases; • To promote scientific research related to home nursing.

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25.2HHCP involved in older persons homecare service in Lithuania: roles and competences CARER/SOCIAL WORKER ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

COMPETENCE in terms of responsibility and autonomy

HOUSEHOLD CHORES

Knows practical principles of household and cleaning Knows living environment of elderly people Knows income security

Has skills in household chores (cleaning, washing, taking care of clothes), shopping, other necessities and firewood or other fuel

Organizes domestic work

NUTRITION

Knows basic about nutrition and healthy diet

Gives information and assistance in administrative matters, etc.

PERSONAL CARE AND ACTIVITIES IN NORMAL DAILY LIFE

Knows principles of personal care Knows standards of Hygiene

Notices a healthy diet and nutrition Prepares meals Assistances in eating and drinking Takes care in personal hygiene Assistances in daily activities

COMMUNICATION

Knows interpersonal skills and techniques of communication and principles of communication in different situations. Knows the Code of Ethics, care-work regulating maintenance manuals, and legislative acts. Knows how to use maintenance manuals and legislative acts in elderly-work. Knows the management of social services.

Supports the client and his/her family

Guides the client and his/her family

Guides the client and her/his relatives.

Guides the client.

ADVISING

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Assistances

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COMMUNITY NURSE ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

NURSING AT HOME

Knowledges of the college (3 to 3.5 years) or university education (4 years): Both receive a bachelor in nursing degree after graduation. “General practice nurse. Rights, duties, competence and responsibility” (adopted by the Ministry of Health, 2004). Knows ageing changes and the resulting personal needs and restriction of operational capacity. Knows physiology and functions Knows principles of personal care Knows standards of Hygiene Knows anatomy and physiology, relevant disease patterns Knows nursing aids Knows how to act in emergency situations Knows nursing documentation (RAI, plan for care and services) Ethics for the professional field of action

Visits at homes and monitors clients working together with a family health condition doctor

CARING ACTIVITIES

NURSING ACTIVITIES AND PHARMACEUTICALS WORK

COMPETENCE in terms of responsibility and autonomy

independent working with clients Gives information and advices

Implements caring activities

Works independentent and follows the caring plan

Gives first aid for seizures, accidents and trauma. Defines the health status Resuscitates Nursing activities Perform scheduled preventive measures Apply nursing aid and care techniques Document observations and measures in the nursing documentation Take measures Implements pharmacotherapy,

working together with a family doctor Works independentent and follows the caring plan

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COMMUNICATION AND ADVISING CLIENT

Knows interpersonal skills and techniques of communication and principles of communication in different situations. Knows the Code of Ethics.

rations and administers pharmaceuticals and monitors their effect Communicates with customers and colleagues in a client-centred way. Can act as a team-member and collaborate with other professionals and service providers.

Guides the client and his/her family Plans home care plan in contact with doctor

RED CROSS’ NURSES ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

CARING AND DAILY ACTIVITIES AT HOME

persons without special education in Perform patient hygiene nursing, who completed specific procedures courses; Knows general principles of hygiene procedures

COMPETENCE in terms of responsibility and autonomy

NON-SPECIALISED NURSING (untrained family members or volunteers such as Samaritans, Caritas’ volunteers and Student Volunteer Organization ‘Patrica’) ROLE: content of the work/sets of activities

theoretical and/or factual KNOWLEDGE

SKILLS as cognitive and practical

DAILY ACTIVITIES AT HOME

Untrained family members or other voluntaries

Helps with activities in daily living or technical procedures Helps with feeding

CARING AND HYGIENE

Courses of one to two months in

Performs personal hygiene

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DOMESTIC AID

duration are organized for volunteers; courses are obligatory. knows practical processes of domestic aid knows safety rules

procedures Helps with activities of daily living and not with nursing and medical support.

25.2.1 References http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf Health Systems in Transition. Vol.13, Nr 2. 2013. Lithuania. Health system review. http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europecase-studies.pdf

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26 OLDER PERSONS HOMECARE IN LUXEMBOURG Background information about dementia and home care services In 1991, a Consultative Commission was set up to look into the possibility of creating a dependency insurance scheme. Users, carers and voluntary as well as private organisations were all invited to participate in the consultation which eventually led to the introduction of a dependency insurance in 1999. This was part of the government’s dual policy to support elderly and disabled people in their own homes for as long as possible whilst at the same time developing user-oriented care strategies. Between 1998 and 2003, 17,933 requests for assistance were registered by the Ministry of Social Security. Of these, 83.2% were from people over 70 and of the accepted applications, 62.6% were from people in need of home care (Ferring and Weber, 2005). Legislation relating to the provision of home care services The Law of 19 June 1998 (“Assurance Dépendance”) led to the introduction of an obligatory dependency insurance on 1 January 1999 (sometimes referred to as long-term care insurance or “LTCI”). This covers expenses linked to the care of elderly residents in old people’s homes or assistance at home. Organisation and financing of home care services The dependency insurance is financed by people (whether they are Luxembourg residents or simply commuters from the surrounding countries) who contribute to the Luxembourg sickness insurance. For the monthly contribution, each person pays 1% of their total gross income (less a quarter of the minimum social salary). There are plans to increase this to 1.4% in the near future (Di Bartolomeo, 2006). For Luxembourg residents, investments, rental and other sources of income are also included in the calculation for annual contributions. Before home care services are provided, a person must have a needs assessment which involves a medical examination and an evaluation of their level of dependency. This is organised by the “Cellule d’Evaluation et d’Orientation” (CEO) which is comprised of a multidisciplinary team under the authority of the Ministry of Social Security. According to the dependency insurance law, a person is considered as dependent if due to a disease or a physical or mental disability, he or she regularly needs a considerable amount of assistance from a third party in order to carry out basic daily tasks (i.e. at least 3.5 hours per week).

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The final decision concerning entitlement to services and the amount of services to be provided is taken by the Union of Sickness Funds (“Union des caisses de maladie”) based on information about the assessment carried out by the CEO. The Union of Sickness Funds is responsible for: 1. the individual classification of dependency, as well as the attribution, reduction and suppression of the different benefits and services; 2. the payment of nursing services, the elaboration of nursing contracts and the negotiation of the monetary value of nursing services; 3. negotiation with service providers concerning the provision of nursing aids (Ferring and Weber, 2005). Dependent people receive a nursing allowance of € 23.85 per hour which can be used to finance informal care e.g. provided by a relative, friend or significant other. However, if the estimated amount of care to be provided is between 7 and 14 hours per week, at least half of the services must be provided by help networks e.g. “Hëllef Doheem”. If the person is in need of more than 14 hours of services per week, such services must be completely provided by the help networks (Ferring and Weber, 2005). In addition to services provided by informal carers and the established help networks, there are about 23 associations, registered with the Ministry of Family Affairs, which operate on a voluntary basis. Kinds of home care services available The person appointed to provide care is responsible for assisting and supporting the dependent person in performing basic acts of living or partially or totally performing these acts for the dependant person. This could include:

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26.1.1 References Di Bartolomeo, M. (2006): information given in speech at the “Cross Atlantic Exchange to advance long-term care” conference held on 13 September 2006 in Bruxelles (organised by AARP and the European Commission) EFILWC (2002), Dependency insurance in Luxembourg,www.eurofound.ie/living/socpub_cstudies/lu1.htm Ferring, D. and Weber, G. (2005), National Background Report for Luxembourg, EUROFAMCARE. http://www.uke.uni-hamburg.de/extern/eurofamcare/documents/nabare_luxembourg_rc1_a4.pdf Hartmann-Hirsch, C. et al. (1999), L’Assurance Dépendance; guide pratique, Ministère de la Sécurité Sociale Horsburgh & Co. S.A. (2005), Assurance Dépendance,www.horsburgh.lu/assurdepend.html

27 OLDER PERSONS HOMECARE IN MALTA 27.1Introduction to older persons homecare service in Malta 27.1.1 Demographic data In 2014 Maltese population was 427,40029 and the life expectancy at birth 81.730. The life expectancy of people over 65 is 20.07 in 2010 and 20.48 in 201431. The average population density per km2 was 1295.3 in 2010 and 1335.5 in 201432 and as a result Malta has the highest population density in Europe. The risk of poverty of the Maltese population over 65 is very low. The following table represents Maltese population in 2010 by age and its projections in 2025 and 206033.

Figure 25: Malta’s present and projected population pyramids (2010, 2025, 2060)

27.1.2 Health and home care in Malta: organization and governance 29

http://data.worldbank.org/country/malta http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators 31 http://data.euro.who.int/hfadb/ 32 http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators 33 National Strategic Policy for Active Ageing: Malta 2014-2020, page 13. 30

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Health services are highly advanced and all residents access to the different services provided by the public centers and hospitals, such as: personal health services, rehabilitative, curative, diagnostic and preventive services. Nevertheless, the share of GDP allocated to social security benefits is lower than the EU27 average.34 The Maltese system is public and centralized at the Government level in terms of governance, regulation provision and financing even if the recent reforms, in particular the Health Act, provides directions to work towards controlled decentralization and autonomy and the involvement of local government in community health care35. The Ministry for Health and the Ministry for the Family and Social Solidarity are respectively responsible for the organization and governance of the health and home care services. In particular, the Ministry for Health is competent in subject of: provision of health services, health services regulation and standards and provision of occupational health and safety. The Ministry for the Family and Social Solidarity has the competence in theme of: social policy and policy relating to the child, the family and people with a disability, elderly people and community care, social housing, social security, pensions and solidarity services. For what concerns the financing of the services, the Ministry for Finance prepares the government budget, collects and allocates taxes and revenue while the two Ministries are responsible for the financing and provision of services within their portfolios. Finally, the organization and the governance includes other actors such as some government ministries, the Foundation of Medical Services, government commissions, agencies, boards and committees, professional regulatory bodies and professional groups, private and voluntary sectors, the Church and the general public. In particular, the public health-care system provides the health services and the private sector complements them, such as in the area of the primary health care and of the long-term and chronic care. The public health-care system provides services to all persons residing in Malta covered by the Maltese social security legislation and to groups such as irregular immigrants and foreign workers who have valid work permits, without any user charges or co-payments for health services. The public health service and private general practitioners (GPs) provide primary health-care services. Specialized public hospitals provide secondary and tertiary care and the main acute general services are provided by one teaching hospital incorporating all specialized, ambulatory, inpatient care and intensive-care services36. In 2011 the first Commissioner for Older Persons has been appointed. Moreover, in 2013, the Department for the Elderly and Community has been moved by the Health Ministry to the Ministry for the Family and Social Solidarity. For some experts, this move implies a shift from a medical to a social policy and as a result the incorporation of the social work services. Nevertheless, the Department has only five social workers mainly dedicated to the assessment of applications for residential, day or home care services37. In the field of Long-Term Care, the services are provided by the state, the Church and the private sector. The first Elderly Care Department was established in 1988. At the present time, the Department for the Elderly and Community offers services to support elderly people such as: home care help, telecare, meals on wheels, 34

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 188. 35 Malta Health system review, Vol. 16 No. 1 2014, Health Systems in Transition, European Observatory on Health Systems and Policies, Natasha Azzopardi Muscat, Neville Calleja, Antoinette Calleja, Jonathan Cylus, page 19. 36 Health Systems in Transition, Malta Health system review, Natasha Azzopardi Muscat, Neville Calleja, Antoinette Calleja, Jonathan Cylus, European Observatory on Health Systems and Policies, 2014, pages 13-16. 37 Long-Term Care of Older Adults in Malta: Influencing Factors and Their Social Impacts Amid The International Financial Crisis, Charles Pace, Sue Vella & Sophia F. Dziegielewski, Journal of Social Service Research, 2016, 42:2, 263-279, DOI: 10.1080/01488376.2015.1129018, 2016, page 271.

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handyman service and incontinence service. Moreover, it also manages day-care centres within the community. Elderly residents residing in state homes contribute 60% of their total income and residents at St Vincent De Paul contribute 80% of their income. The largest care home for old people is the St Vincent De Paul with its 1126 beds, 7 of which are respite beds38. Several services concern the over 75 with disability: outpatient clinics and hospitals, residential homes and community services. These services include domestic aid, personal care, day care, public residential homes for elderly, the Handyman Service, the Incontinent Service, social work units, long-term health facilities. 27.1.2 Home care in Malta policy In Malta, the Social Security Act contains the main legislation on home care39. Moreover, as other European Union Member States, Malta has defined a specific plan, named “National Strategic Policy for Active Ageing: Malta 2014-2020” that also aims at reducing the need for institutionalised care providing. The strategy describes Maltese stance and policy directives in the field of population ageing, encouraging older persons to take responsibility for their own quality of life and well-being. It includes seven key principles: “First, activity refers to all meaningful pursuits which contribute to the well-being of older persons. Second, active ageing policies must involve all older persons including those who are relatively frail and dependent. Third, active ageing is primarily a preventive concept that focuses on the avoidance of illhealth and social exclusion in later life. Fourth, active ageing is intergenerational, with sectors of civil society being stakeholders in this undertaking. Fifth, policies premised on active ageing embody both rights and obligations. Sixth, strategies on active ageing are participative and empowering. Seventh, active ageing is sensitive to national and cultural diversity”. The directives of the Maltese strategy mainly concern: the active participation in the labour market, the participation in society and the independent living. Regarding the independent living, the Strategy focuses on some subjects: the health prevention and promotion, the acute and geriatric rehabilitation, the mental health and well-being, the community care services, the age-friendly communities, the dementia-friendly communities and services, the maximising autonomy in long-term care, the protection from abuse and the end-of-life care. The Strategy focuses on the community care services in different parts providing a set of interesting policy recommendations40. As previously remembered, in 2013, the Department for the Elderly and Community has been moved by the Health Ministry to the Ministry for the Family and Social Solidarity. For some experts, this move implies a shift from a medical to a social policy and as a result the incorporation of the social work services. Nevertheless, the Department has only five social workers mainly dedicated to the assessment of applications for residential, day or home care services41. The Parliamentary Secretariat for Rights of Persons with Disability and Active Ageing (in the following the Parliamentary Secretariat) provides community Services to Older Persons (60 plus) in Partnership with Local Councils. These services include Day Centres Services, Respite Care Services (beds), and Night Shelter Services. Recently, the Parliamentary Secretariat has issued an invitation to targets Local Councils to explore the

38

Malta Health system review, Vol. 16 No. 1 2014, Health Systems in Transition, European Observatory on Health Systems and Policies, Natasha Azzopardi Muscat, Neville Calleja, Antoinette Calleja, Jonathan Cylus, pages 64-65. 39 Social Security Act, Chapter 318, 1st January, 1987 available at http://justiceservices.gov.mt/ 40 See the National Strategic Policy for Active Ageing: Malta 2014-2020. 41 Long-Term Care of Older Adults in Malta: Influencing Factors and Their Social Impacts Amid The International Financial Crisis, Charles Pace, Sue Vella & Sophia F. Dziegielewski, Journal of Social Service Research, 2016, 42:2, 263-279, DOI: 10.1080/01488376.2015.1129018, 2016, page 271.

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possibility that more services are initiated through Public-Private Partnerships, as the non-government sector can play a key role in the future. A mixed financing system is able to continue providing an increasing number of older persons with the optimal level of caring services. As a result, Local Councils have been invited to communicate their proposal describing their available resources, including edifices and human resources as well as proposed forms of assistance they would require from the Parliamentary Secretariat42. The Department for the Elderly and Community offers services of residential cares in various facilities and also residential care in private homes under the Public Private Partnership Scheme. The services aim to support the elderly to continue living in the community and include: Telecare Service, CommCare, telephone rebate scheme, incontinence service, Zejtun night shelter, handyman service, Home Help service and Day Centres. It is also responsible for the issue of the Kartanzjan documents. According to the objective of the project, we are going to describe the services for the elderly relevant for Malta to help the elderly to live at home. Kartanzjan According to the Identity Card Act, Cap. 258, the Electoral Office issues the Kartanzjan card to all the holder of a Maltese Identity Card upon his or her 60th birthday. It entitles its holder to obtain certain benefits in terms of rebates and concessions. Moreover, upon the 75th birthday, it is issued the second type of Kartanzjan and the holders are entitled to the additional benefit such as being granted preference at queues at hospital and health centres43. Telecare Service Plus The Telecare Plus service allows the communication with the Call Centre 24 Hours a day, 7 days a week and enables older adults, disabled persons and those with special needs to call for assistance when required, encouraging them to continue living in their own home and also reassuring the subscriber’s carers and relatives. Moreover, the subscriber is able to call for help from the police, health doctors or relatives. The eligible persons for this service are: elderly couples/persons living alone, aged sixty years and over, disabled persons and those with special needs and, finally, persons of any age with chronic systemic illnesses, living alone and not gainfully occupied. The service is highly subsidized and only few applicants pay the Telecare Plus rental fee, which is €4 a month incl. VAT. The subscriber is also given a pendant with an emergency button and in case of emergency an alarm could be submitted to the call centre. The Call Centre operators organize aid up till first aid is present. Moreover, the service offers different kind of assistances such as an integrated system which reminds to take medicines, messages “I’m OK” towards relatives, etc44. CommCare Unit CommCare Unit acts as a bridge between the health and social care services and ensures that everybody, receiving care in the community area, is appropriately cared for. This unit delivers care applying an interdisciplinary approach; in fact, the team generally comprises nurses, a physiotherapist, an occupational therapist, a social worker, personal carers and administrative staff.45 In particular, the CommCare Unit acts as a regulator for community nursing care, coordinates services and manages care plans for patients on an individual basis, maintains and continues to develop an interdisciplinary approach in case management 42 43

http://www.activeageing.gov.mt/en/Pages/Invitation-for-Collaboration-with-Local-Councils.aspx http://www.activeageing.gov.mt/en/Pages/Kartanzjan/Kartanzjan.aspx

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45

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incorporating both health and social aspects and analyses data collected to address current needs and plan for future developments. The individuals eligible are the individuals whose needs require that care is delivered within their own home, the ones whose independence will be at risk if they are not supported within the community and those who are unable to leave their home due to environmental barriers. All the Government and voluntary entities can receive requests and referrals. The CommCare team makes an initial assessment over the phone and referred for home visits. First time home visits are carried out by one or more members of the team. These visits determine the contents of the assistance and an individual care plan. After an evaluation of needs is done to initiate care and any needed services delivery. People may be referred by the CommCare team to the CommCare Outreach Programme to maximise the independence and ability to live in the community, in his or her own home setting, through a structured plan of intervention. Individuals may also be referred to other community services, such as the community nursing and midwifery care provided all over the Maltese Islands through Health Mark, through the government health service. Health mark employs qualified nurses supported by carers, providing general nursing services such as general care of patients, blanket baths, enemas, wash-outs, wound care, catheterization and treatment for diabetes46. Social Work Unit The Social Work Unit deals with social casework: in particular, it provides psychological support, guidance and assistance, assessments for residential homes and home care help service, liaises with the geriatric, general rehabilitation hospitals, the health Department, Police, Local Councils, Parish Priests and other community organizations, facilitates self-help management and develops action plans. The eligible persons are: older persons living alone with a high level of dependency; those who are of an advanced age; older persons suspected to be suffering from physical, psychological, social or financial abuse; older demented or disorientated persons; older persons living in squalor or homeless elderly people. The service is free of administrative fees47. Day Centres The day centre service helps to prevent older persons’ social isolation and feeling of loneliness and to reduce the social interaction difficulties. It also motivates the elderly to participate to day centre activities and offers respite for relatives and carers. The persons eligible to this service are those over 60 years old, elderly persons living alone, those who are not engaged in social activities and are at risk when spending long hours on their own. For this service it is required to pay a minimal fee, from Eur 2.33 to Eur 5.82, a month. The frequency to attend the day centre depends on the capacity of the particular day centre48. Night Shelter Introduced by the Department for the Elderly and Community Care in collaboration with the Jesus of Nazareth Sisters of Zejtun, the Night Shelter service focuses on the elderly persons who live alone to offer a secure and protective environment. The applicants may be: for Zejtun Night Shelter, elderly females aged 60 and over living alone; for Luqa & Mellieħa Night Shelters, males and females; those who lead an independent life; those not having any other medical condition which may rise any problems with the rest of the residents using the Night Shelter. The fee amounts to 2 Euro per night. The facilities offered at the Night Shelters are: the use of a

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bedroom, a bathroom, a living room and a kitchen. The opening hours are: winter time from 5.00pm till 8.00am and summer time from 7.00pm till 8.00am49. Handyman Service This service helps older adults and persons with special needs to continue living independently in their own home, offering a range of around seventy repair jobs (from electricity repairs to plumbing, carpentry and transport of items, etc.). All senior citizens are eligible and particular: the persons with a Pink form issued by the Department of Social Security (service free of charge); those without a pink form (against a payment); and persons who hold the special identity card issued by the National Commission for Disabled Persons. The rates vary according to the job required. The service is also available for some centres. The client pays the handyman and the latter issues a temporary receipt while an official receipt is issued from the Department for the Elderly and Community Care. Nevertheless, both Pink Cardholders and Non-Pink Cardholders must provide the materials at their own cost. A job is carried out within five days50. Home Help The service offers non nursing, personal help and light domestic work to persons with special needs to aid beneficiaries to keep on living in their community independently and to provide respite for informal carers. The applicants who are sixty years and over are eligible to apply and must contact the Home Help Section at the Department for the Elderly and Community Care. Also persons with special needs under sixty years of age can apply. Finally, all the terminally ill, irrelevant of their age, may also apply. The necessary documents are: the specific application, duly filled with the particulars of the applicant, a medical report and, if available, the copies of recent medical reports or hospital discharge letters. The programmes are customized according to individual needs and a programme is defined: as a result, the number of hours per week may change. The service is free from administrative fees. However, there is a nominal fee per week for every person benefiting from the service. Beneficiaries may request the preparation of meals at an additional fee51 Meals on Wheels The Meals on Wheels service supports elderly persons (and others) that can’t prepare their meal. The nongovernmental organization “Maltese Cross Corps” in collaboration with the Department for the Elderly and Community Care provide the cooked meal. People over sixty years and people with disability are eligible. The interested applicants must contact directly the Meals on Wheels Service and fill the application form. Each meal costs Eur 2.213 and consists of two courses, a roll and a dessert, served in a foil receptacle and delivered in a polystyrene container. The meal is carried out between 9am and 12pm and it is effected in all localities52. Other services Incontinence Service The service alleviates the psychological problem to which a person may be subjected, provides heavily subsidized diapers to decrease the physical and financial strain and finally supports incontinent persons and older adults to continue living in their community. To be eligible, the applicant must: be in possession of the 49

http://www.activeageing.gov.mt/en/Pages/Night-Shelter/Night-Shelter.aspx http://www.activeageing.gov.mt/en/Pages/Handyman-Service/Handyman-Service.aspx 51 http://www.activeageing.gov.mt/en/Pages/Home%20Help/Home-Help.aspx 52 http://www.activeageing.gov.mt/en/Pages/Meals-on-Wheels/Meals-on-Wheels.aspx 50

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special identity card issued by the National Commission for Disabled Persons or be over sixty years of age and suffers from incontinency. The service does not foresee the payment of administrative fees. The responsible unit is the Incontinence Service and a medical doctor defines the number of diapers needed. Then, according to the applicant’s situation a ticket voucher (monthly) or a Green Card (two years) are issued53. National Dementia Strategy and National Dementia Helpline Dementia is a progressive illness concerning brain diseases and causing problems such as difficulties with memory, thinking, communication skills and behaviour and the age is the most important risk factor in developing it. As a result, patients become more in need of help and support in performing everyday activities. In April 2015, the National Strategy for Dementia in the Maltese Islands (2015-2023) was officially launched by the Parliamentary Secretary. It sets out a work programme to enhance the quality of life of individuals with dementia, their caregivers and family members through intervention streams in different priority areas. The number of individuals with dementia is increasing: in 2015 was estimated to be 6,071, 1.5 per cent of the population, and in 2050 it is projected to reach 3.5 per cent. As a result, the demand on the health and social care services will growth too, as the most of the care is provided by family members who act as main caregivers54. The National Dementia Helpline is the first initiative of the National Strategy on Dementia to aid persons with dementia and their families, 24 hours a day by calling the number 1771. It can assist 6,000 individuals and their families. The helpline is managed by four nurses specifically trained to provide instant help in cases of emergency as well as to give information on the services. Finally, the volunteers of the non-government entity, Malta Dementia Society (MDS), work with these people offering help to these persons with a limited helpline55.Other initiatives concern the Dementia Intervention Teams that will be active very soon to provide a high level service in all localities and training for informal carers and the day centres made specifically for those who suffer from dementia. At present, the Dementia Centre at St. Vincent De Paul is a day Centre that opens seven days a week including Public Holidays, from 6.30am till 5.00pm, and offers a safe and stimulating environment, professional trained staff, to maintain an optimal quality of care for individuals with Dementia who still live in the community56. beActive – Active Ageing Project The pilot project beActive, promoted by the Parliamentary Secretariat and aimed to promote new means of active ageing in an adapted environment and with professional trainers, has been held on a permanent basis. More than 200 people have participated. Applicants should be over 60 years of age57. LifeLong Learning Hubs The service is held in Day Centres for the Elderly (transformed in Life Long Learning Hubs) and offers several informative sessions and learning opportunities58.

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http://www.activeageing.gov.mt/en/Pages/Incontinence-Service/Incontinence-Service.aspx http://www.activeageing.gov.mt/en/Pages/National-Dementia-Strategy.aspx and http://www.activeageing.gov.mt/en/Pages/Dementia/Dementia.aspx 55 http://www.activeageing.gov.mt/en/Pages/National-Dementia-Helpline.aspx 56 http://www.activeageing.gov.mt/en/Pages/Dementia-Centre-at-St--Vincent-De-Paul-.aspx 57 http://www.activeageing.gov.mt/en/Pages/beActive-%E2%80%93-Active-Ageing-Project.aspx 58 http://www.activeageing.gov.mt/en/Pages/LifeLong%20Learning%20Hubs/LifeLong-Learning-Hubs.aspx 54

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27.2HHCP involved in older persons homecare service in Malta: roles and competences The HHCP mainly involved in older persons homecare service in Malta can be represented by the CommCare team ones that include: nurses, physiotherapist, occupational therapist, social workers and personal carers. In fact, the team has an interdisciplinary approach and supports individuals remaining in the community. In the recent years, the University of Malta, Faculty of Health Sciences with its 12 Departments, offers degree programmes leading to a health care profession on nursing, occupational therapy and physiotherapy. Moreover, the Faculty is also responsible for the running of Continuing Professional Development courses for registered practitioners. Moreover, the Faculty for Social Wellbeing offers the programme to achieve the Bachelor of Arts (Honours) in Social Work. Nurse, physiotherapist, occupational therapist and social worker professions are regulated by law that establishes ad hoc professional council, boards, etc59. NURSES Malta has a specific legislation that regulates the practice of health care professions: the Health Care Professions Act, Cap. 464. Obviously this Act considers the nurses (and midwives) and foresees that the Register of Nurse is kept by the Council for Nurses and Midwives. The Register consists of parts: • • •

Part I in respect of first level registered nurses; Part II in respect of second level registered nurses; and Special Parts in respect of nurses trained in the different special areas recognized by the Council for Nurses and Midwives60.

Moreover, the COUNCIL regulates the Nursing and Midwifery Professions and the entry to and exit from it. Finally, the Council is responsible for the upholding of high professional and educational standards for both professions61. About nurse training, the University of Malta, Faculty of Health Sciences offer different courses and related certificates, diploma and academic degrees: 59

https://ncfhe.gov.mt/en/services/Documents/Mutual%20Recognition/Designated%20Authorities.pdf Health Care Professions Act, Cap. 464, Part IV, https://health.gov.mt/en/regcounc/cnm/Pages/cnm.aspx 61 https://health.gov.mt/en/regcounc/cnm/Pages/cnm.aspx 60

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Certificate in Clinical Nursing Practice (Adult Cancer Care) (Part-Time Evening), Certificate in Clinical Nursing Practice (Emergency Nursing) (Part-Time Evening), Certificate in Clinical Nursing Practice (Elderly Care) (Part-Time Evening), Certificate in Clinical Nursing Practice (Theatre Nursing) (Part-Time Evening), Diploma in Health Science (Nursing Studies) (Full-Time), Preparatory Course for the Higher Diploma in Health Science (Nursing Studies) (Full-Time), Higher Diploma in Health Science (Nursing Studies) (Full-Time), Bachelor of Science (Honours) Community Nursing (Part-Time Day), Bachelor of Science (Honours) Health Science (Part-Time Distance Learning), Bachelor of Science (Honours) in Nursing (Full-Time), Master of Science in Nursing (Part-Time Day) (Taught and Research, Mainly Taught), Master of Science in Nursing (Full-Time) (Mainly by Research), Master of Science in Nursing (Part-Time Day) (Mainly by Research). In the following tables, the focus concerns: • • •

Diploma in Health Science (Nursing Studies) (Full-Time), Certificate in Clinical Nursing Practice (Elderly Care) (Part-Time Evening), Bachelor of Science (Honours) Community Nursing (Part-Time Day).

NURSE - Level 5 of the NQFL62 The Diploma in Health Science (Nursing Studies) regards a Short Cycle of Qualification. It corresponds to the Level 5 of the National Qualification Framework Level. The course lasts 3 semesters and the attendance is full-time. The ECTS credits amounts to 90. The applicants must have obtained the credits of the Preparatory Course (of three semesters of full-time study) prior to commence the Course. The completion of the studies leads to the registration on the general section of the nurse register of the Nursing and Midwifery Council of Malta. Moreover, the diplomates can join part-time programmes leading to a Bachelor’s degree. Finally, the programme conforms to the European Union Directives on Nursing Education and secures recognition as a first level nurse across EU member states. OCCUPATION - HCCP

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ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

To practice in a professional, accountable manner through critical thinking, knowledge and reflection

To use interpersonal, listening and communication skills To work under pressure

Quality and appropriate nursing care in a variety of

To be competent, caring and professional practitioners, To draw upon the various types

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School nursing, Acute hospital settings, Long-term and rehabilitation settings

health care settings

To know the theories and concepts that underpin and challenge nursing practice To know skills and attitudes central to nursing to function effectively, as a professional nurse To have interpersonal skills to be key members of the multidisciplinary team within any health care setting

coping well in stressful situations To have a caring attitude To uphold professional and personal integrity To be flexible about working hours To have a good background in the sciences, particularly in biology

of knowledge, the appropriate skills and understanding of an individual’s personal wishes To provide the highest possible standard of care To be able to show respect to clients and their colleagues

NURSE - Level 5 of the NQFL63 The Certificate in Clinical Nursing Practice (Elderly Care), an undergraduate certificate programme, focuses on specific fields of practice; it regards a Short Cycle of Qualification. It corresponds to the Level 5 of the National Qualification Framework Level. The course lasts 2 semesters and the attendance is part-time evening. The ECTS credits amounts to 30 at levels 3 and 4. The programme is organised according to clinical pathways. All State Registered Nurses may apply, irrespective of their academic qualifications: nurses who have either a traditional diploma or a diploma from the University of Malta, or an EN-SRN conversion certificate. Nurses with bachelors, masters and doctoral degrees are also eligible to apply. The Applicants must be in possession of the following qualifications: a diploma in Nursing awarded by the University of Malta or a professional qualification deemed by Senate to be equivalent to the qualification. The successful completion renders a candidate eligible for application for enrollment on to bachelor's programmes of studies. OCCUPATION - HCCP

Clinical Nursing Practice (Elderly Care)

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ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

To develop the breath and depth of knowledge, skills and attitudes to be able to deliver, analyze and evaluate the holistic care of patients and their families To have in-depth knowledge and skills

To prioritize the delivery of care for patients with various levels of health care needs To show an understanding of a range of assessment tools and

To demonstrate in-depth knowledge and skills together with an ability to reflect critically on work To be able to provide the highest

Complex, highly skilled activity that requires to work in a multidisciplinary team

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To use knowledge of pathophysiology to make accurate interpretation of physical assessment data To assess the psychological and social needs of patients To deepen knowledge and skill relating to clinical speciality

choice of referral pathways To integrate information which addresses complex health related issues To integrate critical thinking skills in addressing complex health related issues To develop reflective skills To exercise communication skills To improve academic writing skills To manage information through effective retrieval, interpretation and utilization To demonstrate a commitment to professional development

possible standard of care Personal organization and responsibility (including time management)

NURSE - Level 6 of the NQFL64 The Bachelor of Science (Honours) in Community Nursing regards the First Cycle of level qualification. It corresponds to the Level 6 of the National Qualification Framework Level. The course lasts 3 years and the attendance is part-time day. The ECTS credits amounts to 120. Community care is one of the most dynamic and challenging areas in health care. Community nurses work with people and their families and in settings as diverse as homes, health centres, work places and schools, helping individuals and groups with extensively varied health needs. The community nurse is provided with unique opportunities to deliver effective, holistic care. As a result, community nurses face the challenge of working on their own and are members of interdisciplinary teams, often acting as coordinators of comprehensive programmes of care. For these reasons, community nurses receive specialized training for this specialized role. Registered state nurses who are traditionally trained and diploma trained professionals may apply. Preference is given to nurses already working within community settings. Graduates obtain a degree qualification and a specialization in community nursing.

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OCCUPATION - HCCP

Clinical areas: Community and home care, School nursing, Acute hospital settings, Long-term and rehabilitation settings

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

To work in team, with people and their families and in diverse settings To act as coordinator of comprehensive programmes of care

To deliver effective, holistic care To work on their own and in interdisciplinary teams

To face the challenge of working on their own and in interdisciplinary teams, often acting as coordinators of comprehensive programmes of To be able to coordinate care To play a specialized role To have an interdisciplinary approach To help individuals and groups with extensively varied health needs

PHYSIOTHERAPIST65 The Bachelor of Science (Honours) in Physiotherapy regards First Cycle of Qualification. It corresponds to the Level 6 of the National Qualification Framework Level. The course lasts 4 years and the attendance is full-time. The ECTS credits amounts to 240. As the number of students is limited, applicants must satisfy admission and progession requirements (General Entry Requirements for admission, namely, the Matriculation Certificate and Secondary Education Certificate passes at Grade 5 or better in Maltese, English Language and Mathematics and Special Course Requirements, a pass at Advanced Level at Grade C or better in Biology and a pass at Intermediate Level in Physics). The first three years of the course are mainly academic, while the final year is dedicated solely to supervised clinical practice. The completion of the studies make the candidates eligible to apply for registration with the Council for the Professions Complementary to Medicine both locally and in Europe especially the United Kingdom and, once registered, the physiotherapist can look forward to state employment, within the Department of Health, Care of the Elderly, and the Department of Education, as well as employment in the private sector. Moreover, career opportunities exist in academia where access to Masters’ or Doctoral programmes are available and specialization.

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OCCUPATION - HCCP

Clinical areas

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

Diagnostic, ameliorative and restorative roles

High level of theoretical and factual knowledge and practical ability Knowledge of Anatomy, Biomedical Sciences and Physical Science Examination and assessment of patients referred for treatment Diseases processes Technical competence Selection of appropriate intervention

To prevent, diagnose and treat any condition that influences the physical function and performance of the body

To be patient, sympathetic and firm to help patients To encourage, reassure and persuade patients of the benefits of their treatment To be skilled in listening, explaining and report writing

OCCUPATIONAL THERAPIST66 The Bachelor of Science (Honours) in Occupational Therapy regards First Cycle of Qualification. It corresponds to the Level 6 of the National Qualification Framework Level. The course lasts 4 years and the attendance is full-time. The ECTS credits amounts to 240. As the number of students is limited, applicants must satisfy the General Entry Requirements for admission, namely, the Matriculation Certificate and Secondary Education Certificate passes at Grade 5 or better in Maltese, English Language and Mathematics and the Special Course Requirements, a pass at Advanced Level at Grade C or better in Biology. The completion of the studies make the candidates eligible to apply for registration with the Council of Professions Complementary to Medicine and entry to the occupational therapy profession and to register with professional bodies within EU member States. Furthermore, the programme of studies is recognised by the World Federation of Occupational Therapists. Occupational therapists can acquire positions in all parts of the health sector in Malta (as well as overseas) and suitable employment may be found with the local health services, specialist health services, company health services, schools, NGOs as well as in private institutions. Opportunities for professional development and specialization exist too. This programme also provides a basis for Masters’ level degree studies. 66

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OCCUPATION - HCCP

Clinical areas: home, work-place, school or even the community

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

To empower individuals who have sustained an injury, disease or developmental delay to achieve their maximal level of independence in daily life activities, by the use of occupation, purposeful activity, exercise, the modification of the environment and education Health promotion prevention of health problems in those individuals who may be at risk

To work with all age groups To assess and manage a range of clientgroups

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To help to establish the baseline capabilities of the client To modify the environment which may involve adjustments to the home, work-place, school or even the community to allow individuals with disabilities to function optimally in their immediate surroundings To draw up a comprehensive treatment plan To improve the function of the components involved in the carrying out of occupations (such as strength, movement, coordination, endurance, perception and memory) To modify the skills involved in the carrying out of such occupations Education of the family, carers or co-workers

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To develop a range of professional behaviors of relevance to this discipline To be judicious users to promote the adoption of rationale-based methods in all professional endeavors and life-long learning To evaluate Information concerning physical abilities, perceptual, cognitive, psychosocial functioning, environmental aspects and occupational history To guide the client to adapt their habits, routines and lifestyles in order to help accommodate their level of function

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Deliverable 2.1 SOCIAL WORKER67 The Social Work Profession is regulated by “The Social Work Profession Act” that establishes the Social Work Profession Board whose members are appointed by the Minister for the Family & Social Solidarity. The Board processes application for the Social Work Warrant. The Act establishes the “proficiency test” a test having the aim of assessing a person’s ability to pursue the profession of social work in Malta and the Register of Social Worker, as it is a registered work. As a result, “registered social worker” or “social worker” means a person who is registered in the official register of social workers kept by the Board and who has been granted a warrant to practise the profession of social work, in accordance with article 6. Social work means the professional service that is performed to promote or restore a mutually beneficial interaction between individuals as well as between individuals and society in order to improve the quality of life, by aiding persons in receipt of such services to understand, resolve and prevent personal, interpersonal, family or social problems. The social worker usually contacts the person concerned and sets an appointment. Then, according to the particular needs of each individual, the social worker either visits the person in his/her own home, or the person visits the social worker at the Department. The social worker generally makes the assessment of each individual’s situation. Moreover, if the old persons has a family, the social worker may conclude that the involvement of the family can be beneficial to the elderly person, and if the elderly person is willing to involve his/her family, then the social worker makes contact with the family too. The Bachelor of Arts (Honours) in Social Work regards First Cycle of Qualification. It corresponds to the Level 6 of the National Qualification Framework Level. The course lasts 4 years and the attendance is full-time. The ECTS credits amounts to 240. Generally, applicants must satisfy the General Entry Requirements for admission, namely, the Matriculation Certificate and Secondary Education Certificate passes at Grade 5 or better in Maltese, English Language and Mathematics. The University programme is the only route in Malta through which individuals can enter the social work profession, and therefore an important aim of the programme is to expose students to different social work settings in Malta and Gozo. Persons who acquire a Bachelor of Arts (Honours) in Social can work within different social work settings: children and family settings, the drug and alcohol sectors, the disability sector, community settings, health and mental health settings, working with the elderly, working with asylum seekers and refugees and various residential settings. Moreover, the Bachelor of Arts (Honours) in Social Work allows students access to different Masters Programmes both locally and overseas.

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OCCUPATION - HCCP

68

social work

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

Professional service that is performed to promote or restore a mutually beneficial interaction between individuals as well as between individuals and society in order to improve the quality of life, by aiding persons in receipt of such services to understand, resolve and prevent personal, interpersonal, family or social problems

To practice the profession of social work To improve the quality of life of people To deliver services

To pursue the profession of social work To promote or restore a mutually beneficial interaction between individuals To promote or restore a mutually beneficial interaction between individuals and society To aid persons in receipt of such services to understand, resolve and prevent personal, interpersonal, family or social problems

To be equipped to work with vulnerable individuals in society To appreciate diversity and individuality To identify strengths in people and communities and to seek to develop those strengths and build on them

HOME HELPER69 Finally, in Malta there is the home helper, usually a part-time social assistants providing. This worker must have a clean conduct certificate by the police authorities. 68

CHAPTER 468, SOCIAL WORK PROFESSION ACT, To make provision for the regulation of the social work profession and to, provide for matters connected therewith or ancillary thereto, 1st June, 2004, ACT XVII of 2003, as amended by Legal Notice 427 of 2007, available at https://sites.google.com/site/maswmalta/home/social-work-profession-board; and http://www.um.edu.mt/socialwellbeing/overview/UBAHSWKFTIII-2014-5-O 69 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 190.

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OCCUPATION - HCCP

Home helps

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

Domestic aid

No required level of education

-

-

27.2.1 References Social Security Act, Chapter 318, 1st January, 1987 available at http://justiceservices.gov.mt/ Health Care Professions Act, Cap. 464, Part IV, https://health.gov.mt/en/regcounc/cnm/Pages/cnm.aspx CHAPTER 468, SOCIAL WORK PROFESSION ACT, To make provision for the regulation of the social work profession and to, provide for matters connected therewith or ancillary thereto, 1st June, 2004, ACT XVII of 2003, as amended by Legal Notice 427 of 2007, available at: https://sites.google.com/site/maswmalta/home/social-work-profession-board http://www.um.edu.mt/socialwellbeing/overview/UBAHSWKFTIII-2014-5-O National Strategic Policy for Active Ageing: Malta 2014-2020 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013 Health Systems in Transition, Malta Health system review, Natasha Azzopardi Muscat, Neville Calleja, Antoinette Calleja, Jonathan Cylus, European Observatory on Health Systems and Policies, 2014 Long-Term Care of Older Adults in Malta: Influencing Factors and Their Social Impacts Amid The International Financial Crisis, Charles Pace, Sue Vella & Sophia F. Dziegielewski, Journal of Social Service Research, 2016, 42:2, 263-279, DOI: 10.1080/01488376.2015.1129018, 2016 http://www.activeageing.gov.mt/en https://ncfhe.gov.mt/en/services/Documents/Mutual%20Recognition/Designated%20Authorities.pdf https://health.gov.mt/en/regcounc/cnm/Pages/cnm.aspx http://www.um.edu.mt/healthsciences http://www.um.edu.mt/socialwellbeing/overview/UBAHSWKFTIII-2014-5-O http://data.worldbank.org/country/malta http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators http://data.euro.who.int/hfadb/ 562634-EPP-1-2015-IT-EPPKA2-SSA

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28 OLDER PERSONS HOMECARE IN NETHERLANDS 28.1Introduction to older persons homecare service in Netherlands The Netherlands, even if is a small country, is densely populated with 16.7 million of inhabitants. Currently, the proportion of persons with pensionable age (over 65 years) is below the European average, even if it is expected to grow. According to statistics, life expectancy is 81.12 years, 79.02 years for male and 83.34 for female70. THE HEALTHCARE SYSTEM The healthcare system of the Netherlands is governed by four basic healthcare-related acts/pillars that represent the foundation of the Dutch healthcare system: •

the Health Insurance Act (Zorgverzekeringswet) - ZVW 2006,

•

the Long-Term Care Act (Wet langdurige zorg) - WLZ 2015/2016,

•

the Social Support Act (Wet maatschappelijke ondersteuning) - WMO 2015,

•

the Youth Act (Jeugdwet) - 2015.

In addition, there are several general laws in place (including the Competition Act/Mededingingswet) and other specific healthcare acts (e.g. the Care Institutions (Quality) Act). The Health Insurance Act, for hospital care, and the Long-Term Care Act, for other types of care, account for the bulk of the healthcare budget available in the Netherlands. The Long-Term Care Act is a national act governing healthcare throughout the nation. In implementing the Health Insurance Act, private health insurance companies play a key role in a system based on “regulated competition” and a number of specific public requirements. Other forms of care and support are provided by the Social Support Act and the Youth Act: the roughly 400 municipalities in the Netherlands are primarily responsible for enforcing these two acts. In 2006, with the new Health Insurance Act, all residents of the Netherlands are entitled to a comprehensive basic health insurance package. This act is implemented by private, competitive health insurers and healthcare providers. The entry into force of this act has transformed the Dutch healthcare system from a supply-driven to a demand-driven system. The Dutch healthcare system is essentially a private system but the government plays a role of control in order to protect the public interest and to guarantee the social nature of the health insurance. The Dutch healthcare system is considered a “hybrid” from different points of view:

70

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It is universal and inclusive, financed through general taxation, concerning the exceptional expenses (long-term care, home care and residential care for the frail elderly and the physically and mentally disabled).

•

It is mutual because the standard curative care component is guaranteed by insurance companies; the insurance is compulsory and the government supports low-income citizens.

•

It is based on market rules because insurers are private organizations that operate in a competitive environment.

The current structure of the system is designed by the reforms of 2006 and 2015, awarded by a ranking system71, very generous and, also for this, very expensive. HEALTH INSURANCE ACT As already mentioned, the Dutch health insurance system combines elements of public and private insurance. The central government is not directly involved in the actual implementation of the Health Insurance Act: the procedures involved are determined by healthcare providers, health insurers and insured parties. This structure ensures that healthcare providers have a great deal of freedom, while competition and market forces create the incentives required to work efficiently and at a high quality level. The government decides which types of care are included in the package and when this care should be provided but the health insurers have to guarantee that the services included in the basic insurance package are available to all their policyholders. It is possible to integrate with a supplemental insurance that is fully private with no governmental rules. The core set of health benefits that insurers are legally obliged to cover includes: services provided by GPs, hospitals, specialists and midwives; prescriptions; maternity care; medical aids and devices; limited access to therapeutic services and ambulatory mental health care; outpatient and inpatient mental health care for up to a year; all dental care for under 18s; specialist dental care and dentures for adults. But there are some limits on the services covered and certain treatments are excluded. Therefore, health services are funded by a mix of obligatory social and private insurance, with additional copayments for long-term care. LONG-TERM CARE, YOUTH HEALTH SERVICES AND SOCIAL SUPPORT The recent reform of 2015 has introduced the Long Term Act, the Social Support Act and the Youth Act. The aim of the reform is to keep people self-supported as long as possible. Most forms of non-residential care will be transferred to the municipalities and added to the Social Support Act (WMO, in place since 2007). Insurers will be responsible for home nursing. The Long-Term Care Act is administered by special long-term care administrators at the behest of the central government and, additionally, several other organisations are involved in its implementation.

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The local authorities are responsible for implementing the Social Support Act and the Youth Act – they provide the support, assistance or care services or are supported by a healthcare provider. The objective of these laws is to improve the quality of the care provided, promote an integrated approach, and keep healthcare available and affordable in times of an ageing population and in which many people suffer from chronic illnesses. A person that requires permanent supervision or 24-hour home is entitled to care services under the Long-Term Care Act. The first step of this reform process is the abrogation of the General Exceptional Medical Expenses Act. Since 2015, all long-term care is provided under the Long-Term Care Act, which is strictly intended for the most vulnerable categories of people. In order to provide effective and high-quality care, the local authorities, being much closer to the people, are responsible for administrating and implementing the Social Support Act and the Youth Act. LONG-TERM CARE ACT The 1st January 2015, the Long-Term Act entered into force replacing the General Exceptional Medical Expenses Act: people who require permanent or 24-hour home care can take advantage of provisions under this healthcare-act. With the reform The Exceptional Medical Expenses Act (ABWZ) is replaced by the Longterm Care Act (WIz), for those who are unable to live at home. Municipalities are responsible for home care and added to the pre-existing Social Support Act (Wmo), while home nursing care is provided and organized by health care insurers. In contrast with the past act, the Long-Term Act applies to a smaller group of people: most vulnerable groups in the society, such as elderly people in advanced stages of dementia, people with serious physical or intellectual disabilities, and people with long-term psychiatric disorders. The Centrum Indicatiestelling Zorg (Care Assessment Agency) gives special-needs assessments to these people based on a national, standardised format. Clients who have received a special-needs assessment can receive care either at home or in a care home or similar facility. The Long-Term Care Act is administered by special long-term care administrators at the behest of the central government. These administrators have transferred the actual implementation to healthcare administration offices that are designated in each region and which are closely affiliated to a health insurance company. They organise the way the healthcare services are provided. The Long-Term Care Act is a compulsory health insurance policy based on solidarity: anyone who pays income tax in the Netherlands pays premiums under this act. The main parties of the LTC are: clients and their representatives, the central government, the Care Assessment Agency, the Dutch Healthcare Authority, the healthcare administration offices and the healthcare providers. If the clients are not satisfied with the care provided, they can choose another healthcare provider. For those who want to manage their own healthcare needs, they have their “personal healthcare budget”. They also have the option to submit a complaint to healthcare providers, the healthcare administration offices and the Healthcare Inspectorate. The healthcare administration offices can set quality requirements when 562634-EPP-1-2015-IT-EPPKA2-SSA

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purchasing care under the Long-Term Care Act. In addition, they also check that the statements sent by the health insurance companies match the care specified and the production agreements made. The most common functions are: •

stay in a care facility: long-term stay, or being placed in a nursing home or designated, sheltered accommodation for people with mental disabilities;

•

personal care: assistance with washing, dressing, using the toilet, and eating and drinking;

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care that increases self-reliance: assistance in structuring the day, gaining greater control over one’s life, and learning to perform household duties;

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nursing care: medical assistance, e.g. tending to wounds or administering injections;

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treatment under the Long-Term Care Act: a medical, paramedical or behavioural treatment which helps with the recovery or improvement of a specific condition;

•

transport to and from day programmes and day treatment: for people whose medical condition prevents them from travelling to the day programme or day treatment independently.

The central government decides the types of care of the healthcare package under the Long-Term Care Act, advised by the National Health Care Institute. The healthcare administration office manages long-term care based on the special-needs assessment provided by the Care Assessment Agency and discusses the situation with the client, who can then state their preference for specific healthcare providers. Alternatively, it is foreseen a personal healthcare budget, whereby people purchase and organise their own healthcare. The client, together with the healthcare provider, draft a healthcare plan (for contracted care) or a budget plan (for personal care), while the healthcare administration office informs the healthcare provider that the care can be provided. The healthcare provider subsequently provides the care as agreed in the healthcare plan or budget plan. Funding healthcare under the Long-Term Care Act A the Long-Term Care Act is a statutory social insurance, people pay an income-dependent premium through their payroll tax. The amount of the premium is based on a fixed percentage (9.65%) of the income tax (maximum amount of EUR 33,589). The adult that wants to take advantage from the services offered by the Long-Term Care Act has to pay a personal contribution, on the basis of the income and of the personal situation: if he/she lives at home or in a care facility, is younger or older than 65, and is single, married or has a domestic partner. The National Healthcare Institute is responsible to manage all the contributions that are deposited into the Long-Term Care Fund. The central government tops up the fund using public funds if these funds are too low. There are different forms of financing, depending on whether the client has opted:

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•

for contracted care: a portion of the fund is transferred to the Central Administration Office (CAK). The latter subsequently pays the healthcare providers at the behest of the healthcare administration offices; personal healthcare budget: a portion of the fund is transferred to the Social Insurance Bank (Sociale Verzekeringsbank/SVB), which manages the personal budgets for holders of such budgets. Those responsible for organising healthcare based on a personal healthcare budget are entitled to special drawing rights from the Social Insurance Bank: the invoices from the healthcare providers (up to a maximum amount) are sent to the Social Insurance Bank, which pays these invoices.

SOCIAL SUPPORT ACT The responsibility of providing support to people with disabilities has been transferred to the local authorities with the Social Support Act 2015; including people with physical, mental or psychological disabilities, and people with learning disabilities and the elderly. The aim is to ensure that people can continue to be productive members of society and to enable them to continue living at home. In addition, local authorities can provide sheltered accommodation and support to people who have no other options or who are unable to live at home. Local authorities support people who have difficulty participating in society or who cannot take care of themselves or have a need for sheltered accommodation or support. As it follows, a partial list of the services offered:          

assistance and day programmes/daytime activity; household support; support by an informal carer; volunteers; a place in a sheltered environment (sheltered accommodation) for people with long-term psychological disorders; support for men, women and children who are victims of domestic violence; social support, e.g. for people who are homeless; financial support for people who incur significant additional expenses on account of their chronic illness or condition.

HOME CARE IN THE NETHERLANDS Home care has a long tradition in the Netherlands. In 2006, government and stakeholders have developed a quality framework and norms for effective, efficient, safe and client-centred home care72 and, in 2008, a governmental statement emphasised the importance of transparency to the public, concerning the quality of care services73. The Ministry of Health, Welfare and Sport (Ministry of VWS) is the main responsible for home care but decision-making has been decentralised and directed by market force.

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Deliverable 2.1 There is near universal coverage, with fewer than 0.2 per cent uninsured74. With regard to the allocation and contracting of nursing and personal care services at home, it has largely been delegated to regional ‘care purchasing offices’ linked to the health insurance companies. Municipalities are responsible for domestic aid and some technical aids and decide on the eligibility of these services and negotiate prices with providers. Home care services are provided by almost 1000 admitted private agencies operating locally or regionally in competition75. The majority of the agencies are not-for-profit but the number of commercial agencies is increasing. The Netherlands has been the first country to establish a universal social insurance scheme for social care needs in 1968. With the 2015 reform, by its inclusion in the Health Insurance Act, home nursing is placed closer to other types of primary care such as GP care. Health insurers become responsible for the whole medical domain, from home nursing care to specialist hospital care. Home nurses combine their medical tasks with improving the cohesion between prevention, care, well-being and housing. Recovery focussed mental care for adults (18 and over) will also become the responsibility of health insurers. The home care sector is considered an important source of employments in the Netherlands. Most numerous are “domestic aids”. The majority works part-time and are female. In contrast, in the sector of home nursing and personal care, permanent contracts are usual. Working conditions and payment for home helps and home nurses are set at national level in collective labour agreements. Home nurses’ salaries are around the median wage, while the salaries of home helps are below it. BUURTZORG The “Buurtzorg” phenomenon is an innovative approach in the Netherlands to deliver home care. “Buurtzorg”, which means “care in the neighbourhood”, has originated in 2006 from staff’s dissatisfaction of traditional home care organisations. It has attracted international attention for its innovative use of independent nurse teams in delivering highquality, relatively low-cost care. Buurtzorg was set-up by Jos de Blok (himself a former nurse) who envisaged a reformed district nursing system in the Netherlands. The model consists of small self-managing teams of a maximum of 12 professionals (comprising both nurses and other allied health professionals) and aims for keeping organisational costs as low as possible, partially by using ICT for the organisation and registration of care. The aim of this approach is to engage three key national health priorities: health promotion, management of conditions, and disease prevention.

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The social care and health systems of nine countries - Commission on the Future of Health and Social Care in England NZa 2007

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From the LTC process point of view, Buurtzorg introduces a built-in attempt to contact and integrate with other local carers and with informal caregivers. Buurtzorg aims to deliver care to a client for as short a period as possible, by involving and reinforcing the client’s resources. Buurtzorg responds to the client’s care needs, tries to find solutions together with the client and his informal carers and other formal carers involved, arranges things around care and social life and supports self-decision of the client about what is necessary. This may explain the very high user satisfaction scores. By mid-2010, teams were active in 250 locations nationwide. So far, data on patients’ satisfaction show that it is extremely high. Also satisfaction of staff and of co-working GP’s is very high. At the same time indications are that Buurtzorg home care is only about half as expensive as usual home care76. KINDS OF CARE SERVICES AVAILABLE Among the services that are offered by the home care system, below, a list of the main ones:  Home nursing (e.g. giving advice on how to cope with an illness, dressing wounds, administering medication),  personal care (e.g. assistance with dressing, bathing, personal hygiene, eating and drinking),  home help and housekeeping (e.g. cleaning, tidying and preparing meals),  day care,  respite care,  night care,  assistive devices. Concerning the domestic aid and supportive aids, the criteria for access to them are regulated by municipalities: eligibility is independent of income but co-payments are general and dependent on income and type of service. Also the personal situation is considered. For an effective, efficient, safe and client-centred home care, a quality framework has been realized for the nursing and caring sector. Measurable norms for the quality of care have been developed by stakeholders, patient organisations and the Health Care Inspectorate (IGZ): the “Consumer Quality index for Home Care” (CQI Home Care). The IGZ is responsible for supervision on quality of services. In addition, home care agencies are annually obliged to monitor and improve the quality of services and staff through reports. Every two years, the home care agencies organise client evaluations and the municipalities have to assess the clients’ satisfaction with domestic and services each year. The results of quality assessments are available on the website http://www.kiesbeter.nl. The individual providers are not obliged to be accredited, however, the agencies providing home nursing or personal care, financed through the Exceptional Medical Expense Act, have to be registered. The municipalities are the main actors specifically for domestic aid and supportive aids: they develop local regulation on eligible services, organise needs assessment, finance providers and decide on prices and 76

Interlinks - Health systems and long-term care for older people in Europe. Modelling the interfaces and links between prevention, rehabilitation, quality of services and informal care. RCN Policy and International Department Policy Briefing 02/15 August 2015 The Buurtzorg Nederland (home care provider) model

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providers. Part of domestic care (through the municipalities) is provided by home care agencies and part by commercial cleaning enterprises. For the procurement of home care, municipalities are obliged to write a tender, but they also have to observe that clients are able to make a choice between providers.

28.1.1 References Indexmundi Healthpowerhouse.com The social care and health systems of nine countries - Commission on the Future of Health and Social Care in England Interlinks - Health systems and long-term care for older people in Europe. Modelling the interfaces and links between prevention, rehabilitation, quality of services and informal care. RCN Policy and International Department Policy Briefing 02/15 August 2015 The Buurtzorg Nederland (home care provider) model The social care and health systems of nine countries - Commission on the Future of Health and Social Care in England Healthcare in the Netherlands – Ministry of Public health, Welfare and Sport, January 2016 The Health Systems and Policy Monitor Home care across Europe – Case studies

28.2HHCP involved in older persons homecare service in Netherlands: roles and competences In the Netherlands, the education of the individual health carer, health and welfare assistant and care assistant is regulated. The main figures that are involved in the provision of Dutch home care are the following: •

Nurses

•

Carers: they work in nursing homes, home care and retirement homes.

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Administrative staff: the desk clerks make appointments with patients, provide general information, and receive visitors.

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Professionals from other disciplines: social workers, physiotherapists, psychiatrists, etc.

•

Divers (medical) staff: surgical assistants, dietary aides, technicians, application manager, staff kitchen and transport service.

The Dutch nursing system is structured as follows: -

Level 1: Zorghulp (Auxiliary helps/Care assistant) This person doesn't really help the patient himself, this person cooks, cleans, whatever that kind of work.

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Level 2: Helpende (Home helper/health and welfare assistant) This person helps the staff with the care for the patient, they aren't allowed to do any reserved act like medication or injections.

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Level 3: Verzorgende (Individual health carer) This person takes care of patients, give them their medications but can only do certain reserved acts.

The first three level can be classified as “caregivers” group. All three levels are on the level of intermediate vocational education, which is organised by one of the regional education centres, accredited by the Ministry of Education, Welfare and Sports. Each level has its own conditions regarding the duration and the content of the education. The qualification of these compulsory educational preparations is recognized nationally. The institution regulating the education is called Calibris (Landelijke Kwalificaties intermediate vocational education Verzorgenden IG) being responsible for the accreditation of training companies and the maintenance of the qualification for the sectors Care, Welfare and Sport. There is no mandatory registration for level 1 and level 2. But, as individual health carers (level 3) have also tasks and duties in the range of the working field of registered nurses (technical nursing procedures) , they are required to register in the BIG register. The BIG register wants to protect patients or care receivers against incompetent and negligent acts of caregivers. The skills and competences demanded by the workplace differ in each level. General important skills of all three levels are to give physical and emotional support to patients. For individual health carers (level 3) also the nursing procedures like medication, injections, feeding tubes and other technical nursing procedures are very important skills. Furthermore, the Dutch nursing system, considers other levels that correspond to the “nurse” figure verpleegkundige: -

Level 4: MBO-Verpleegkundige

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Level 5: HBO-Verpleegkundige

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Verpleegkundig Specialist : Master of Advanced Nursing Practice (MANP)

NURSES Along with doctors, nurses are among the most important professionals in health care. In today's health care institutions nurses work with the most advanced equipment, they are involved with innovative treatment plans, they direct care and, as trend watchers, must monitor health risks both for individuals and groups and take (preventative) action (this is also called public health). The study of nursing is an education in a profession of health care aimed at caring for people to help them gain or recover their health and quality of life. Nursing is a healthcare profession ensuring the well-being and health of patients. Nurses are responsible for the proper implementation of medical prescriptions and giving patients the care they require. Those trained in nursing are involved in everything from tutoring and supervising new

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nurses and students, acting as a team leader and delegating work. Nurses also keep in contact with patients and their relatives on a daily basis. They support and evaluate treatments and therapies in order to ensure an optimal recovery. Figures from the national statistics office CBS show there were 180,000 registered nurses in the Netherlands at the end of 2014, a drop of around 33% on the previous year. The decline is due to the introduction of new rules requiring all nurses to re-register in the Dutch health professionals register BIG: it is not possible to work as a nurse in the Netherlands without being in the BIG register. Nurses who had not had sufficient patient contact and training in the previous years were automatically scrapped. There are several programs for the nursing job. It is possible to follow nursing course at MBO (institutes for intermediate vocational education) level or HBO (institutes for higher professional education) level. There are also specific Master's programs for nurses. The Bachelor of Science in Nursing (BSN) is internationally recognized. (Permanent Advisory Committee on Nursing Affairs “The Profile of the Nursing Profession” cited by Oud Nicholas in “The Netherlands” in Quinn and Russell The European Dimension (Scutari Press, 1993), p. 160.)

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LEVEL 1: ZORGHULP – AUXILIARY HELPS OR CARE ASSISTANTS The auxiliary help works in contact with young people, the elderly, people with disabilities, patients who are just out of the hospital, people with health problems and the family of the clients. No training is necessary but a one-year vocational training is available.

In order to be an auxiliary help it is necessary to: • •

at least have reached the age of 18 years, being able to speak and write Dutch. This qualification is still possible for inhabitants of The Netherlands for whom Dutch is not their first language and who have lower language skills. The duration for trainees with little language skills is 1.5 years, as they are trained in language courses too.

The figure is able to work in nursing homes, care facilities and in clients' homes.

In the first half year, there is training at school. In the second half year, there is both, school and internship (21 hours a week). (Home care Across Europe; Contee Project) ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

Facility management Providing home care Providing help with daily tasks and activities /

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SKILLS know how to do - SKILLS as cognitive

Household work; Signalling functions; To help the client in their daily activities (helping clients with daily personal care such as washing, dressing, using the toilet and feeding themselves carrying out general tasks such as housework, laundry and shopping, etc.).

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Friendly and caring approach and the ability to relate to people ; Patience and a sense of humour are also important.

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LEVEL 2: HELPENDE - HOME HELPER/HEALTH AND WELFARE ASSISTANT

The training of the health and welfare assistant (level 2) lasts 2 years. The course consists of eight periods of ten weeks. The first two periods (20 weeks total) are at school. After 10 weeks, they start with an internship of one day per week that introduces them to the practice. After the 3rd period, the internship time is 2 days a week. ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

To provide care and support based on a work plan; Support the independent functioning; Perform organization and profession-related tasks. /

SKILLS know how to do - SKILLS as cognitive

To create a work plan based on the care-, living-, activity plan; To give household support for the living area maintenance; give support with personal care/activities of daily life; support social activities; how to act in unexpected situations; support of client/care recipient in emotional area; support of client/care recipient in coping.

COMPETENCES know how to be

Friendly and caring approach and the ability to relate to people ; Patience and a sense of humour are also important.

LEVEL 3: VERZORGENDE - INDIVIDUAL HEALTH CARER The Training for individual health carer (level 3) lasts 3 years. Two ways to accomplish the education are possible. Either one decides to study full time (40 hours a week) with internships breaks or one does his degree with a 24 hour working contract (minimum) at an acknowledged apprenticeship institution and additional education days.

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ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

To provide care and support based on the care plan; Supervise the care recipient, based on the care plan; Perform organization and profession-related tasks

/

SKILLS know how to do - SKILLS as cognitive

To make a care plan; support in basic personal care; provide palliative care; support for household and living; perform of nursing procedures; monitor of health in both somatic and psychosocial areas; provide information, advice and instruction; able to act in unforeseen crisis situations; accompany the care recipient in coping strategies ;accompany the care recipient in psycho-social areas; accompany the care recipient in the social field; supervise a group of care recipients in the social field; provide guidance in a specific industry (e.g. elderly homes, people with intellectual handicaps etc); work on professional development and professionalization of the profession; work on the promotion and monitoring of quality; tune of the different care actions; evaluate the care.

COMPETENCES know how to be

Friendly and caring approach and the ability to relate to people ; Patience and a sense of humour are also important.

LEVEL 4: MBO-VERPLEEGKUNDIGE The MBO Nurses work with people who need specialist help or care due to illness, old age or disability. The accompaniment varies by patient. They can face with situations where the (mental) health of the care recipient changes rapidly. This relates to situations where intensive treatment, therapy or medication is applied. They work independently and are partly responsible for drawing up care plans.

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The MBO-4 nursing training can be in two ways: through the Apprenticeship Training (BBL, working and learning) and through vocational training (BOL, learning and internships). In both cases the training takes four years. Exemptions: In certain cases it is possible to shorten the training (with relief for a number of subjects) to follow. This is the case when they are in possession of a diploma MDGO VZ (long) and MDGO VP or if they already have (volunteers) experience. It is possible to evaluate they experience through an EVC procedure (Recognition of Prior Learning). You can sign up for an EVC procedure at an ROC. Following an EVC procedure are costs attached. ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

To draw up care plans; To supervise an apprentice or trainee.

/

SKILLS know how to do - SKILLS as cognitive

COMPETENCES know how to be

To discuss and report of changes in the nursing situation; provide information on care recipients; To give medication and perform nursing skills; nurse care and counselling; support and guide rehabilitation, chronically ill or demented caretaker co-ordination of the total nursing process;

LEVEL 5: HBO-VERPLEEGKUNDIGE The level 5 nurses learn how to deal with patients with disabilities (threatening) illness or disability. They get theory of ethics, physiology and anatomy of the body. In addition, they learn the organization of care.

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Many graduate nurses usually work in nursing home, hospital, psychiatric institution, etc. The HBO bachelor nursing can be followed via different pathways: full-time, part-time or via the dual variant. They work on the recovery of patients in the ward care, hospital or psychiatry. They play a pivotal role and coordinate the contact among patients, carers and other professionals. They can work in all sectors of health care. They learn which nursing care the patient needs and how to give this care (in more complex situations) and how then implement a nursing plan. The nursing care is patient oriented and is determined in consultation with the patient and his family. You also work on care programmes, nursing policy, quality care, care renewal and expertise stimulation. ROLE (SET OF ACTIVITIES)

/

KNOWLEDGE know what - theoretical and/or factual knowledge

To focus on the patient with his demand and needs

SKILLS know how to do - SKILLS as cognitive

To work on care programmes, nursing policy, quality care, care renewal and expertise stimulation

COMPETENCES know how to be

Patient oriented and determined in consultation with the patient and his family

(Avans-hogeschool, Hanze University of Applied Science)

VERPLEEGKUNDIG SPECIALIST: MASTER OF ADVANCED NURSING PRACTICE (MANP) A nurse practitioner is a Master of Science educated nurse (NLQF/EQF level 7) who has completed the Master Advanced Nursing Practice, which is accredited by the NVAO (The Accreditation Organisation of the Netherlands and Flanders). He/she has previous experience in nursing on a Bachelor of Nursing level, and is employed to treat a defined group of patients with whom he/she will engage in an individual treatment relationship. From the patient’s perspective, care and cure are offered jointly to promote the continuity and quality of both nursing care and medical treatment. The patient’s ability to self-manage and safeguarding his/her quality of life play a central role. The title ‘Nurse Practitioner’ is protected by law and exclusively reserved for those who have completed a Master Advanced Nursing Practice and are registered in the specialist register.

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The nurse practitioner is registered in the specialists register (article 14) of the BIG Act (the Netherlands Individual Healthcare Professions Act). With the coming into force of the experimental article 36a and the corresponding government decree of 1 January 2012, the nurse practitioner can lawfully enter into an independent treatment relationship with a patient. A nurse practitioner as defined in article 14 of the BIG Act distinguishes him/herself from a regular nurse as defined in article 3 of the BIG Act. The nurse practitioner fulfils the role of a clinical expert. (Verpleegkundigen & Verzorgenden Nederland) ROLE (SET OF ACTIVITIES)

KNOWLEDGE know what - theoretical and/or factual knowledge

To work in somatic or mental healthcare and have competences in both the nursing and medical area. To provide care on an expert level and medical care in accordance with protocols in his/her area of expertise

NURSE PRACTITIONER

SKILLS know how to do - SKILLS as cognitive

COMPETENCES know how to be

To provide patient-oriented care on an expert level; To take care of effective communication and interaction with patients and other parties involved; To collaborate with other professionals on the basis of equality with the objective of realising optimal patient care; To participate in the decision-making involved in organising care in the different fields of the healthcare system; To promote the health and the well-being of patients and population groups; To contribute to the development and implementation of clinical and scientific knowledge and the spreading of nurse practitioner expertise; all this to ensure an ongoing learning process;

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To contribute to the development and implementation of clinical and scientific knowledge and the spreading of nurse practitioner expertise; all this to ensure an ongoing learning process; To practice the profession in an expert, qualitatively good manner, resulting in an accurate assessment of the individual situation of a client, professional intervention, a specific treatment plan and always acting in a procedurally correct way.

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29 OLDER PERSONS HOMECARE IN POLAND 29.1Introduction to older persons homecare service in Poland Poland is the largest country in central and Eastern Europe and covers an area of 312,685 square kilometers77. In 2015, the Polish population amounted to 38,612,000 and the life expectancy at birth, after years of decline, has reached for both sexes 77.5 years (of which 81.3 years for women and 73.6 years for men) and the healthy life expectancy at birth has reached 68.7 years78. The total expenditure on health as % of GDP reached the 6.7 in 201379. Elderly people remain at lower risk of poverty. In Poland, the families are the main source of care for the elderly80. As other European Union Member States, basing on the European Year for Active Ageing and Solidarity between Generations, or EY2012, Poland has worked on a new conception of the senior policy and implemented the National Programme of Social Activity for the Elderly for 2012-2013 (Rządowy Program na rzecz Aktywności Społecznej Osób Starszych na lata 2012 - 2013) and has created the Advisory Council for Seniority Policy (Rada ds. Polityki Senioralnej)81. Thanks to this experience, the Council of Ministers has adopted the so-called “Package for Seniors” on December 24th, 2014, that is the Long-term Senior Policy in Poland for years 2014-202082. In fact, the main causes of the changes of the European society demographic structure are the low fertility rates and lengthening of life expectancy. As a result, the proportion of older people (60 +) is growing everywhere and also in Poland83.

Moreover, Eurostat data show that people over 60 years will represent nearly 25% of the population of Polish society in 2020. These data are confirmed for Poland by the Central Statistical Office (forecast for 2008 – 2035)84.

77

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 214. 78 http://apps.who.int/gho/data/node.main.688?lang=en 79 http://www.who.int/countries/pol/en/ 80 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, 215. 81 Long-term senior policy in Poland for the years 2014-2020 in outline, page 53. 82 Long-term senior policy in Poland for the years 2014-2020 in outline, page 4. 83 Long-term senior policy in Poland for the years 2014-2020 in outline, page 6. 84 Long-term senior policy in Poland for the years 2014-2020 in outline, page 7.

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As a result, Poland has defined its “Senior policy” that includes a package of actions performed by public administration at all levels and other organizations and institutions that perform tasks and initiatives shaping the conditions of a dignified and healthy aging85. In the last decades, Poland is transforming its health care system from a centralized architecture to a decentralized organization86. Home care is situated within the health care and social assistance systems. The Ministry of Health is responsible for health policies and regulations and the Ministry of Labour and Social Policy is responsible for social policy and its implementation. The National Health Fund, Narodowy Fundusz Zdrowia - NFZ, is responsible for signing contracts for the delivery of specific health care quality services (Law on Health Care Services Financed from Public Sources 2004). Moreover, health services financed from NFZ are generally free of charge for insured persons. Services from social assistance are financed by local authorities and are frequently co-paid for by the users. The typical home care services are mainly the primary care delivered by family physician and family nurse; the new home care services are the long-term home nursing care, the home hospice, the home care for people with complex needs and medical rehabilitation at home. They are financed from health insurance. According to the Law on Universal Health Insurance with the National Health Fund 2003, co-payments apply to the costs of medicine, dressings and other specialised supplies. Taxation is the main source of funding of social assistance services (basic personal care, house cleaning, shopping and supply of meals) that are financed by the local governments (community “gmina” and district “powiat”), the central budget and by the client’s co-payments proportionate to their income. On the community (gmina) level assistance is provided in the place of residence of the beneficiary and day care homes (half-institutional assistance). Assistance may include financial help (permanent, temporary and intentional benefits) and services (home aid and some personal care). At the district level some specialized services (e.g. counselling, rehabilitation) and social care homes are organized. An additional source of financing is the National Disabled Persons Rehabilitation Fund (PFRON). The Law on Social Care (2004) describes the role of governmental administration and local governments87.

85

Long-term senior policy in Poland for the years 2014-2020 in outline, page 8. Health systems in transition, Vol. 13 No. 8 2011, Poland Health System Review 2011, European Observatory on Health Systems and Policies, World Health Organization, 2011, page 47. 87 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 215, 217-218. 86

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Social sector services are paid per hour of care and may be carried out by local authorities or be delegated to profit and non-profit organisations (Polish Red Cross, Caritas, Polish Social Care Committee)88. Nowadays, according to the Law on Health Care Services Financed from Public Sources 2004, the NFZ manages the obligatory health insurance premium contribution which pays the health services that are generally free of charge for insured people. In this framework, long-term healthcare can be delivered at patients’ homes unless they choose to stay at long-term care residential institutions, usually not classified as hospitals, which are cofinanced by the clients. The social assistance mainly consists of cash benefits and non-financial support such as services in the form of social work, care services and specialist counseling. It is organised by units of central and local administration in cooperation with other organisations (foundations, associations, churches, religious groups and employers): municipalities and communes - social assistance centres; districts (poviats) - poviat centres for family support, in regional social policy centres - voivodships89. In Poland, traditionally, the family takes care for elderly and/or disabled people. Nevertheless, changes in the families and in values have been observed as well as the decline of the member in feeling responsibility for care. The home care for the elderly is included in the framework of the long term care services. At the present, the organisation of long-term care services in Poland is well represented by the following figure both for public and private services90.

Figure 26: Framework of the long term care services

88

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 218. 89 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 214. 90 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, page 22.

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Institutions that provide health and social services usually work separately and, as a result, there is insufficient cooperation between the health and social care sectors mainly due to their separation. In most cases, healthcare professionals (i.e. family nurse, family doctor or long-term home care nurse) and an informal carers play the role of coordinator91. As shown in the figure above, public long term care services92 for dependent elderly are provided by: • •

the health sector, including a range of medical services; and the social sector, including care for dependent elderly people in a socially difficult situation (living alone, come from dysfunctional families, or poor).

These sectors deliver both home care and 24/7 residential care services. In addition, cash transfers are available to different types of beneficiaries, such as older people and dependent people with motor disabilities. In particular, home care93 comprises nursing services, delivered by means of the health sector and managed by the primary health care units after the assessment of health needs, and care services delivered by the social sector and managed by the social assistance centers that previously assess the income and the family difficult conditions. Finally, special cares are targeted at people with mental health problems. The home care services of the NFZ delivered at the patient’s home concern the care provided respectively by the primary care nurse and by the long- term home care nurse. All insured patients are eligible for primary care nurse service and can choose their primary care nurse. The nurse plans and delivers complete nursing care in a primary care practice, identifies and assesses the patients’ health needs and, finally, executes shortterm doctor’s orders. Moreover, the nurse has the following tasks: health promotion, nursing care and collaboration with other agencies94. The long- term home care nurse services are those services directed towards the needs of any chronically ill and handicapped patients staying at home. In these cases the eligibility is based on Barthel index and is monthly reassessed. For this service some limitations exist as the demands exceed the supply of services contracted by NFZ95. The domestic aid service (but also basic personal care) depends on the system of social assistance: it consists of services at home bases on a persons’ needs and the personal situation. It may include: basic personal care, house cleaning, shopping, being brought to a doctor, etc. In this case, the client may financially participate

91

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 219. 92 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, page 22. 93 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, page 22. 94 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 215. 95 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 215.

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according to his/her income. These services are mainly delivered to persons without family support, or when family care is ineffective96. The health and the social sectors also provide public residential services97 with different eligibility criteria, financing rules and types of services. The health sector offers care and treatment facilities (zakład opiekuńczoleczniczy ZOL), nursing and care facilities (zakład pielęgnacyjno-opiekuńczy ZPO) and palliative care homes; the social sector offers two kinds of residential homes: stationary (social assistance homes – DPS) and family nursing homes that can accommodate full-time residents including those persons who require permanent institutional care. Different types of family nursing homes exist in Poland. Family nursing homes provide care and residential services 24/7 from three to eight people and are targeted at the elderly or the disabled persons who require a permanent assistance. Semi-residential care services98 are provided by the local governments. In particular, the social assistance centers manage day nursing homes dedicated to old people living with their family but whose members cannot provide them care due to their professional activities. The services are generally provided between 09.00 am and 04.00 pm, 5 days a week. Day nursing homes provide a range of activities such as excursions, exhibitions, etc. Cash benefits99 are provided by public institutions to specific types of and needs for care and include old people. In particular, the benefits concerning the elderly are: • •

Nursing benefit (zasiłek pielęgnacyjny) is a care-related benefit granted to different people included the over 75 years of age; Care supplement (dodatek pielęgnacyjny), a universal benefit granted to persons entitled to an oldage, disability or survivors’ pension who are over 75 years old as well as to persons of any age who are entitled to an old-age, invalidity or survivors’ pension, and are completely incapable of working and need every-day assistance.

Orthopaedic equipment and assisting means prescribed by a doctor of a particular specialization, are subject to a refund from the NFZ (up to a certain price). If the patient is not able to pay the costs over the price limit or if the equipment is not refunded by the NFZ, the district level social assistance center may grant money from the National Disabled Persons Rehabilitation Fund (PFRON) budget100.

96

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, pages 215-216. 97 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, pages 22-23. 98 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, pages 24-25. 99 The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, page 25. 100 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 216.

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Deliverable 2.1 The following table represents the services and benefits related to long-term care101. Social assistance/Family benefits

Health sector

Day care

Care facilities (ZOL, ZPO), hospices, and palliative care units -

Social services

Assisted living facilities

Residential care

Cash benefits

Social assistance homes (DPS) Day care centers Home services and specialized home services Nursing benefit (zasiłek pielęgnacyjny) to caregivers of disabled children and people 75+ (153 PLN/month)

-

Social security

-

Care supplement (dodatek pielęgnacyjny)universal benefit to 75+ (206.76 PLN/month)

Table 36: the services and benefits related to long-term care

In Poland a remote tele-care service is not financed by the public sectors and, to use it, it is necessary to pay by own resources102. Home care personnel In Poland, to practise defined health professions, it is necessary to be member of the specific chamber. Professional chambers Physicians, dentists, pharmacists, nurses and midwives, and laboratory diagnosticians are associated in professional chambers that represent their interests. In particular, the chambers implement different activities, provide expert opinion or arbitrates on professional responsibility matters, participate in the establishment of the education standards, maintain the registers of licensed and active professionals, develop ethical codes of practice and may impose disciplinary measures on their members, etc103. The profession of nurse is defined by the Law on Nurse and Midwife Profession (1996) and by the Decree of the Minister of Health regarding the type and range of preventive, diagnostics, therapeutic and rehabilitative services provided by nurse or midwife independently without doctor’s order (2007) which also describes the area of competence of the nurse (such as dressing of burns and wounds, treatment of bedsores, condition of additional training104). To practise as a nurse, generally, it is necessary to have a nursing bachelor’s or master’s degree, according to the Decree of the Minister of Health regarding the guaranteed services in the field of nursing and caring services in long-term care (2009); long-term home care nurses should be qualified having a 101

The Present and Future of Long-term Care in Ageing Poland Policy Note, The World Bank, 2015-11-30, page 26. Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 220. 103 Health systems in transition, Vol. 13 No. 8 2011, Poland Health System Review 2011, European Observatory on Health Systems and Policies, World Health Organization, 2011, page 23. 104 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 217. 102

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qualification course and/or specialization in fields such as long-term care, family care, chronically ill and disabled people’s care or internal or geriatric nursing105. Finally, if a nurse remains out of the job for five years it is required to undergo training and pass recertification exams106. To be a social worker, it is required to meet one of the following conditions: 1. To have a diploma from the College of Social Service Workers, 2. To be graduated from university in the area of social work, 3. To be graduated from university with a specialization preparing for the profession of social worker (Law on Social Care 2004). The professional qualifications on providing formal care services are changing and in recent years it aims to replace unskilled workers in the field of home care. As a result, the education system is changing too107.

29.2HHCP involved in older persons homecare service in Poland: roles and competences As already mentioned, in Poland, public care for dependent elderly people is provided through two sectors: • •

the health care sector that includes cases of dependency care, requiring a range of medical services; the social sector that includes care for dependent elderly people who are also in a socially difficult situation (i.e. living alone, come from dysfunctional families, or are poor).

Following this logic, also home care is provided in the two sector. Traditional home care within the healthcare system is provided almost exclusively by primary care (family physician and family nurse). In the framework of the long-term care, at present, new forms of home care services have been created, such as: home nursing care, home hospice, home care for people with complex needs and medical rehabilitation at home. The main figures involved in the LTC home care in Poland are: for the health care sector: nurses for the social assistance sector: social workers Within the social assistance system, domestic aid and basic personal care at home is provided by the “home care assistants”, which offers basic personal care, house cleaning, shopping, transport, etc. Financial participation of the client depends on the income and only if it is below social assistance criteria, the client gets the right to free services.

105

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 216. 106 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 217. 107 Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, 2013, page 217.

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Nevertheless, recent studies show that care for the elderly disabled people in their home environment is mainly based on informal networks of family carers108. NURSES Forms of nursing health services contracted by the NFZ and delivered at the patient’s home and include care provided by: 1. PRIMARY CARE NURSE 2. LONG-TERM HOME CARE NURSE The profession of nurse is defined in law by the Law on Nurse and Midwife Profession 1996 and by the Decree of the Minister of Health. According to the law, nurses have the right to professional independence and can sign separate contracts with clients. PRIMARY CARE NURSE The primary care nurse plans and delivers comprehensive nursing care in a primary care practice and at a patient’s home. In order to practice as a nurse, it is necessary to have a nursing bachelor’s or master’s degree. LONG-TERM HOME CARE NURSES In 2004, the NFZ has introduced a new form of nursing care: the long-term home care nurse. This type of nurse is addressed towards the needs of any chronically ill and disabled patients staying at home. Long-term home care nurses should have a qualification course and/or a specialization in fields such as longterm care, family care, chronically ill and disabled people’s care or internal or geriatric nursing (Decree of the Ministry of Health regarding the guaranteed services in the field of nursing and caring services in lont-term care 2009). The long-term home care nurse needs a referral from the doctor.

108

Home Care across Europe, Case studies, Edited by Nadine Genet, Wienke Boerma, Madelon Kroneman, Allen Hutchinson, Richard B Saltman, European Observatory on Health Systems and Policies, World Health Organization, page 221.

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NURSES OCCUPATION

ROLE

KNOWLEDGE

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

To do a variety of everyday basic nursing procedures. To plan and deliver comprehensive nursing care in a primary care practice and at a patient’s home.

NURSE

PRIMARY CARE NURSE

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SKILLS

COMPETENCIES

know how to do - SKILLS as cognitive (involving the use of know how to be logical, intuitive and creative thinking) and practical (involving competence in terms manual dexterity and the use of methods, materials, tools and of responsibility and instruments) autonomy, being able to evaluate, making judgements, managing a complex task in a context taking decisions, etc. To identify and assess the patients’ health needs, health To perform their promotion, nursing care and collaborate with other agencies. profession with due To perform a self-evaluation of the services provided, making a diligence, in nursing diagnosis and a care plan. accordance with the To diagnose patients’ condition and their health-related needs; principles of medical To identify patients’ needs related to nursing; ethics, by respecting To plan and provide nursing care of patients; patients’ rights and To independently provide any preventive, diagnostic, taking care of their treatment, rehabilitation as well as medical emergency services, safety, and to the in the specified scope; best of their current To perform medical orders in the diagnostic, treatment and medical knowledge. rehabilitation process; To decide on the kind and scope of nursing services; To teach how to exercise the profession of a nurse and take certain measures aimed at the professional training of nurses; To conduct scientific and research work in the field of nursing; To lead and manage nurses’ teams; To be employed in healthcare facilities in administrative positions, which shall entail performing activities related to arranging for, organising or supervising the provision of 336 of 418

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healthcare services.

LONG-TERM HOME CARE NURSE

To be specialized in longterm care, family care, chronically ill and disabled people’s care or internal or geriatric nursing.

To provide physical and psychosocial support to patients and their families.

29.2.1 References Ministry of Health Republic of Poland http://www.mz.gov.pl/en/healthcare-system/health-personnel-and-training/nurses-and-midwives/

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30 OLDER PERSONS HOMECARE IN PORTUGAL 30.1Introduction to older persons homecare service in Portugal The territory of Portugal includes an area in the Iberian Peninsula (called the continent by most Portuguese) and two archipelagos in the Atlantic Ocean The population is nowadays 10.339.000 people, with a population density of 125 inhabitants/ km. In 2014 the population over 65 years amounted to 20.01% and the aging index (number of elderly / 100 youth) was 138.6. Life expectancy (in 2013) at age 65 was 17.2 years for males and 20.6 years for females. The healthy life expectancy or disability-free life expectancy, at age 65 (in 2014) was 6.9 years for males and 5.6 years for females The provision of health care and social support at home aims to the maintenance of users in their family and social environment. It takes place on two levels I. Through the "network of national care continued integrated" II. By social benefit of home support systems National network of integrated continuing care "(RNCCI). " The RNCCI is made up of entities public and private (Private institutions of Social solidarity (IPSS) and Holy House of mercy) that provide continued care health and social support when necessary, to persons in a situation of dependence, at home or in other institutions. They used four types of resources: 1 - inpatient units. 2 units for outpatients. 3. hospital equipment of continued health care and social support. 4 equipment home of care continued health and social support.

30.1.1 Home of care continued health and support teams Extension and capacity : The RNCCI is distributed all over the country with the set of all resources is able to offer attention, in data of February 2016, to 6.289 users: 1673 - North; 846 - Center; 2136 - Lisboa e Vale do Tejo; 549-Alentejo e 1085 Algarve. Access to the seats is subject to existing availability. Regulatory authority : Ministry of labor and Social solidarity (MTSS), and ministries of health. (MS) Financing : Co-financing. A part of the MTSS, National Health Service (belonging to MS), private institutions of solidarity Social (IPSS), Santa Casa de Misericordia , or the users own. On the other hand the user, who only pays the costs of social support, total or partial form depending on the economic situation of personal and family. Dependence and coordination: • level National: MTSS • level Regional: regional administrations of health of each of the five existing areas: North, Central, Lisboa and Vale do Tejo, the Alentejo and the Algarve; Through giving them regional coordination teams • Local: teams, in principle of municipal level. The teams local coordinators are composed of at least one doctor, a nurse, a social worker and, whenever necessary, a representative of the local authority

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Profile of beneficiaries : ∙ functional dependence (unless motor) temporary or prolonged complex ∙ elderly fragility ∙ severe disability criteria, with a strong psychological impact or social ∙ disease severe in advanced or terminal phase. * Pre-requisite prior availability of some social support and not need hospitalization Gateway to the service : ∙ users in hospital: through the management team of high ∙ users in the community: from the center of health through the doctor or social worker. SOCIAL BENEFITS SUPPORT HOME Social benefits support home Is a system of social support that offers seven types of resource: ∙ Centre of coexistence; ∙ Centre day ∙ middle of night ∙ residential structure for elders∙ family shelters for older persons and adults with disabilities ∙ homecare service. 30.1.2 Home care service Focusing on the "family helpers" who are workers who provide care basic social support, persons in situations of dependency, in their home. Gateway to the service: • • •

Directly in the institution or establishment of social support that provides support; Santa Casa da Misericórdia of Lisbon. Care of the residence Social security services. This type of service availability can also be found in the list of social resources on the web site of "the Social Charter".

Profile of beneficiaries : People who are in their homes in situations of physical or psychological dependence and cannot ensure, temporarily or permanently, the satisfaction of their needs of daily life, or have family support for the purpose. Financing ( : 1) Co-pay of the user (only in the aforementioned institutions) according to family income. 2nd) subsidy from Social Security.

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30.2HHCP involved in older persons homecare service in Portugal: roles and competences OCCUPATION / HHCP Nurse of general care

ROLE

KNOWLIDGE

SKILLS:

COMPETENCIES

-Preventive, -Healing, of -Rehabilitation or -Hospice

-Use assessment tools to identify actual and potential risks. -Administration of medication.

- Provides support / education in the development and maintenance of the capacity for independent living. -Ensures that the individual and / or caregivers to receive and understand information about care to that will be provided. -Establishes priorities for care, when possible, in collaboration with individuals and / or caregivers. -Implement infection control procedures.

Nurse specialist in Rehabilitation nursing

-Physiotherapy (+) -Preventive, -Healing, of -Rehabilitation or -Hospice

Not specified

-Identify architectural barriers and prepares proposals for their elimination. -Provides rehabilitation care. -Creates and administers grants for technical support,

-Formulates a plan of care, wherever possible, in collaboration with individuals and / or caregivers. -Review and reformulate the plan of care on a regular basis, whenever it is possible, in collaboration with individuals and / or caregivers. -Ensures the safety of the administration of therapeutic substances. -Participates with members of the health team in making decisions regarding individual ao. -Review and assess loscuidados with members of the health team. -Consulted experts in nursing, when nursing require a level of expertise that is beyond their current competition or out of the limits of his exercise area. -Consultation with other professionals and organizations sanitary needs of individuals or groups over their exercise area. -Creates, implements, and controls the rehabilitation plans based on health problems real and potential resulting from a change in the functional capacity of the elderly and/or alteration of the way of life that results from disability / disability or chronic illness. -Take decisions related to the prevention of secondary complications/disabilities, health

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Nurse specialist in nursing in Psychiatry and mental health

-Mental health-related aspects (+) -Preventive, -Healing, of -Rehabilitation or -Hospice

Not specified

Nurse specialist in nursing of community health

-Training And information about prevenciaon (+) -Healing, of -Rehabilitation or -Hospice

Not specified

-Health promotion through information and education strategies. -Promote coping mechanisms to deal with situations of suffering, minimizing the impact of mental illness in individuals, families and groups. -Provision of care people elderly, families and groups with mental health problems, enabling through therapeutic and psychotherapeutic interventions to facilitate their adaptation, - Assisting individuals, families and groups more vulnerable and subject to exclusion factors.

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promotion, treatment and rehabilitation, maximizing the potential of the person. -It promotes maximum independence in ADL and the quality of life -Promotion of mental health in the elderly, families and groups, enabling them to adopt healthy behaviors for positive and active aging; -Prevention of mental disorders, allowing people to develop protective factors, reduce risk factors, with emphasis on reducing comorbidity of mental illness in people with chronic disease or long-term evolution. -promote the recovery, rehabilitation and psychosocial rehabilitation - includes care for people with chronic diseases or prolonged evolution, promoting processes of adaptation to disease, death or mourning processes follow. -Create, implement, and evaluate educational strategies to train the person and the community in the pursuit of health and citizenship projects, helping people and families to experience the processes of transition and not normative events and help vulnerable and risk groups such as older persons dependent on the achievement of the health benefits and improve the quality of life. -Establish network of causality of the problems with the determination of the causes and factors of risk and, therefore, stimulate and lead programs for intervention in the field of prevention, protection and promotion of health. and health -Cooperate with the health and social services

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network. assisting individuals, families and groups more vulnerable and subject to exclusion factors. Nurse specialist in nursing of health of the elderly and Geriatrics

-Aspects of the geriatric patient care -Preventive, -Healing, of -Rehabilitation or -Hospice

Not specified

Not specified

OCCUPATION / HHCP FAMILY ASSISTANTS

ROLE

KNOWLIDGE

SKILLS:

-Help in the task of food, clothing, hygiene and comfort.

Help home -Food hygiene -Basic knowledge of Gerontology and disability -Basic knowledge of Gerontology and disability

COMPETENCIES

- Preparation and drug and food administration

-Mobilization techniques -Hygiene of the bedridden

-Basic knowledge of Gerontology and disability

-Give users the prescribed medication

-Adapt to the changes that will check on the overall situation of the users. -Act in order to overcome situations of isolation and loneliness;

-Human relations -Family economics

-Collaborate with families, ensuring adequate information on the relevant aspects to ensure the health and well-being of families -Carry out services abroad and accompany

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31 OLDER PERSONS HOMECARE IN ROMANIA 31.1Introduction to older persons homecare service in Romania General information about the country Extension 238.391 km2 (9th largest EU country) Population: 21 million people, (7th largest country in the EU). 16.5% of the population is older than 65. The forecast for the year 2050 is that this rate will reach 30%. Population in a situation of dependency At the end of 2015, the dependent population was 766 153 people. The 40, 89% of the dependent population has more than 65 years being predominantly women. The 2.3% are institutionalized in public nursing homes. 97.7% remaining are at home being cared by caregivers or family. Health coverage: Health expenditure is higher than the EU average. The Ratio of nurses and doctors is less than EU average. There is a big difference between urban and rural areas, due to the accessibility problems, financial situation and geographical environment, as well as by the limited existing health transport network. The quality of care will depend on the social situation because there is only a basic coverage. Health care at home is given by the home care team, which is composed by a social worker, doctors, psychologist and nurse. Related with their performance and needs valuation, the social coverage can be derived. Other professionals involved in home health coverage are the nursing assistants, which intervene medically. Physical therapist, involved very occasionally, also after medical indication and finally almost testimonial form the speech therapist. Occupational therapists are basically responsible for the transition from hospital to home and proposes the adaptation of the House, but don´t perform any other activity directly with elders. Social protection: Public social attention focuses mostly on orphanages and psychiatric institutions. Elderly care in institutions is low, it has a social-health character and it is carried out • elderly care Hospital (equivalent to nursing homes in other countries), which is accessed by a doctor report. • Nursing homes of the State, less health care and more social. • Private nursing homes with or without profit. Elderly´s needs attention at home It shows a very irregular distribution across the country. The legislative instability for years has directly affected this coverage. 562634-EPP-1-2015-IT-EPPKA2-SSA

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There is a framework regulation that defines, under cover of law 17/2000, who are the elderly beneficiaries of the home care. These would be the following: people without family or caregiver assigned. People who have no home ownership or sufficient financial resources. People whose income is not enough to be able to take care of yourself alone. People with health problems who need specialized help. People with physical or mental problems who do not can take care of themselves. Also under the protection of the law 292/2011 are defined standards of services, which are classified in: • services basic social assistance (of documentation management) • support services, • monitoring of medical treatment. Assistance in transport Regulatory authority: Ministry of labor, Social Security and family. Main document: order of the Ministry of labor 2126 / 2014, annex 8, laying down minimum quality standards for home care for the elderly services Financing and access: Home care services are financed through public funds, (with very small amounts allocated to Central or local budgets). It does not allow part-time or hourly payment for services. The same co-pay formulas are used. When service providers are direct relatives, there are formulas for compensation in the form of the labor and social benefits of face to the retirement of the caregiver. There is also a private coverage, usually through NGOs The indication by doctor or medical specialist hospital after suffering an illness that has needed hospitalization is required for access to home care.

31.2HHCP involved in older persons homecare service in Romania: roles and competences The coverage is carried out through two networks: Informal network: formed by family, neighbors and friends; It supports more than 90% of the attention. The relatives are a group of support which is essential. Network of authorized caregivers by the Government: with or without training. • Caregiver without certifying: the vast majority • Personal assistants: generally follow the training given by the local authority which authorizes them, but no particular requirements. • Certified for elderly caregivers: often complete a training program for six months (620 hours) in care for the elderly, and receive a certificate; • Caregivers certificates for ill persons they attend

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Training of careers It is delivered from the public sphere or from the private sphere, in this case mostly by NGOs. The training courses have a variable length, from a few hours. The courses that have accreditation recognized are given from a length of 360 h contents theoretical and practical. Level of primary education (8 years) is required. Training courses, are developed in modules or topics, sometimes they have defined certain powers, but not defined explicitly and generally specific knowledge, skills, roles, etc., even if they come partially developed programs. Nursing: own nurses can act in this sector health and social mix. There is a lack of information regarding the work of the nursing home. There is the possibility of working on their own as a nurse at home but requires authorization. NURSE KNOWLEDGE

SKILLS

COMPETENCIES

1. the process of care - definition, stages, care plan

(b) To administer the treatment as prescribed by the doctor.

(a) the establishment of the needs of care of the overall health and the provision of services in general health care, prevention, cure and rehabilitation.

-Basic needs

(d) To develop programs and health education activities;

-Techniques for patient care 2. the administration of drugs.

(c)The protection and improvement of health.

(e)To facilitate actions to protect the health of groups considered to be at risk.

3. the biological and pathological processes 4.emergency medical or surgical -cardiopulmonary resuscitation -Polytrauma - fractures, sprains, dislocations, hemorrhage and Haemostasis

To educate

(f) To research in the field of the health care in general nurse responsible for general licensees. (g) The participation in the protection of the environment. (h) The preparation of reports written on the specific activity carried out.

-The transport of the patient polytrauma

(i) Organization and the delivery of community health care services.

in respiratory disorders, cardiovascular systems, obstetrics and Gynecology at the Pediatric

(j) The training of nurses theoretical and practice in general education programs.

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5. the care of patients with respiratory diseases -

(k) the auxiliary medical staff training;

6. the care of the patients with cardiovascular disease

(l) To carry out educational activities in the schools to prepare

7. the care of the patients with kidney disease

Future nurses.

8. the care of patients with gastrointestinal diseases 9. the care of patients with neurological diseases education 10. the care of patients with psychiatric disorders 11. the care in pediatric patients 12. the care of patients in obstetrics and Gynecology. 13. the care of the patients with skin problems - health education - The manifestations of independence, dependence (Signs and symptoms) -Diagnostic care -Objectives and interventions -Appraisal techniques -Health plan 14. the care of patients with infectious and contagious

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diseases -health education 15. the care of patients in ICU 16. the care of the patients with surgery

OLDER ADULTS CAREGIVER

KNOWLEDGE

SKILLS

COMPETENCIES

-Verbal and non-verbal techniques...

- To receive and transmit information

-Communication

-General rules of labor protection

-To respect the general norms of labor protection

-Professional development

-Mobilization techniques

-To administer drugs, help practitioners to perform cures.

-The planning of daily activities

-Assess the behavior of the assisted person

- To fill the care sheet

-Management of resources allocated

-Evaluation of appetite

- To carry out mobilization and transport

-Compliance with requirements medical:

-To check the vital signs: (blood pressure, FC,

-Monitor the health of the assisted person

Temperature, f. respiratory)

-Ensure the comfort of the elderly

- To make hygiene care

-Ensure hygienic conditions,

-Help nutrition and manage food -Apply first aid to the assisted person

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32 OLDER PERSONS HOMECARE IN SLOVAKIA 32.1Overview on the older persons homecare service in Slovakia In 2013, 13.96% of the population of Slovakia was older than 65 years, which is less than the EU27 average of 18.02% and ranks among the lowest values. The old-age support ratio, i.e. the ratio between people of working age (20–64) and people after retirement age (over 65), in 2013 was the highest value among the EU member countries [Szudi et al, 2016].The population over 65 at risk of poverty is extremely low, with 8% compared to 19.6%on average in the rest of the European countries [Genet et al., 2013]. The Slovak system relies heavily on institutional care and informal care provision. The most important part of homecare is the informal care, most often given by family members or close contacts of the care recipient [Szüdi et al., 2016]. Informal carers are formally recognized. According to the Act on direct payment of Compensation of Disability (N447/2008) they can receive an income dependent care allowance. As the basic amount is around € 200 per month it does not cover full-time involvement [Szudi et al, 2016]. Long-term care lacks integrated home care, community, ambulatory or hospital health and social services. Both social and health care are subject to different legal frameworks and their competences fall into two different sectors [Szalay et al., 2011]. The need of complex home care in Slovakia has an increasing trend both for clients/patients and for healthcare workers. Inquiries show that as many as 90% of citizens prefer to have health and social care provided within their own home settings. In Slovakia homecare has generally one of these three objectives [Lezovic et al., 2011]: -

to substitute hospital-based acute care; to substitute institution-based long-term care; to prevent the need for institutions and maintain individuals in their own homes and communities.

Home healthcare is a new type of care in Slovakia. It is considered homecare both the care provided indoors (at home), and the care provided outdoors (in a community). This care represents the primary healthcare in Sloviakia [Lezovic et al., 2011; Genet et al., 2013].; as a matter of fact home care recipients are almost triple the number of institutional long-term care recipients, which is considerable compared to the other countries. In the framework of this system, the medical care and social care services for the elderly are separately organized .Governance on home care is split between home nursing (which belongs to health care) and formal home care i.e. personal hygiene and household chores: after a failed legislative attempt to integrate the two kinds of service, a strict division in terms of financing still exists; medical care services are financed by the Ministry of Health through the health insurance payments, while, under the auspices of the Ministry of Labor, Social Affairs and Family, social care services are financed at lower administrative levels (in the case of elderly people, municipalities) through taxation (about two thirds of the social care expenses) and clients copayments (about one third of the social care expenses) [Genet et al., 2013].

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Partly due to the division in terms of financing and service provision of medical and social care, the home care system faces several challenges [Szudi et al, 2016]: -

some eligible people do not receive the indicated care. inefficient assessment procedures for applying for public financing. insufficient financial resources; inequality: access to social services varies greatly by local and regional policy institutions [Genet et al., 2013]; unequal funding of public and private providers. Such descrepancies are an obstacle to competition.

An overview of the usual types and length of services in selected facilities is presented in the following Table.

Table 37: Overview of the social and medical services provided in the Slovak Republic [Radvanský & Páleník, 2010].

32.1.1 Home healthcare in Slovakia Although GPs (or their nurse) are legally obliged to visit patients at home, this only occurs sporadically. Home nursing (but personal care as well) is primarily provided mainly by a single type of organization, namely ADOS (agentúry domácejo etrovateskej starostlivosti)- home care and nursing agencies. Thre are about 162 ADOS in Slovakia [Szudi et al, 2016]. These agencies are part of primary healthcare and they belong to the system of healthcare services. They provide complex special nursing care for clients/patients, families, communities within their own habitat. It is a self-contained functional unit allowing the provision of nursing care including prevention, therapy, rehabilitation, counselling, healthcare, as well as social and educational care [Radvanský & Páleník, 2010]. The service is free of charge after the insurance companies have assessed the individual level 562634-EPP-1-2015-IT-EPPKA2-SSA

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of disability and found the client to be eligible ADOSs are part of the primary health care system and do not generally provide home assistance such as help with shopping, cooking, or cleaning [Szudi et al, 2016]. Access to home nursing care formally requires a physician’s referral. Thereafter, an agency’s nurse will assess the client’s degree of mobility, draft a treatment plan and assign the intervention nurse. The plan needs approval from the health insurer. In practice this procedure may not always be followed [Szudi et al, 2016].

32.1.2 Social homecare in Slovakia Home care services are provided by municipalities and self-governing regions or, on their behalf, by private providers (either for profit or non-profit, such as charity organisations, Red Cross). However, most roviders are public, although the revised Act on Social Services is said to have complicated financing of private providers and thus to make private provision less attractive. At national level the eligibility to personal care and domestic aid/formal home care has been defined in the ‘Act on Social Services’ (Act N 448/2008) and legislation on ‘Direct payment of Compensation of Disability’ (N447/2008) [Szudi et al, 2016]. A social worker will assess the social situation, while a physician will examine the patient’s health status. Medical devices and technical aids are prescribed by GPs and paid by the public health insurance agency. Other devices and technical aids are paid from state budget via financial allowance for severe disability compensation. Equipment for distant monitoring is on the market, but not widely used as public funding for it is missing. Integration between institutional care and social home care social workers are the formal liaison. They must arrange the smooth transfer of patients from an institution to their home

32.2HHCP involved in older persons homecare service in Slovakia: roles and competences A professional qualification to perform activities in various health occupations, which is called the basic qualification in Slovakia, can be obtained after completing: • • • •

a Bachelor’s or Master’s degree in an accredited university programme higher vocational training full secondary vocational training secondary vocational training.

Professional qualifications to perform specialized professional activities can be obtained through a specialized course/training. Professional qualifications to perform certified professional activities can be obtained through certified training. Specialized training, certified training and continuous education of health workers are called “further education/training” in the Slovak system. Until 2004, the Slovak Health University was the sole provider of further education. Since 2004, other institutions, accredited by the Accreditation Committee of the Ministry of Health, including medical faculties, may offer training and education for health professionals. Life-long continuous medical education is obligatory for every health professional. Relevant professional chambers perform evaluations of continuous education at five-year intervals. In case of shortcomings, the professional organization may warn the employer or may notify the HCSA. It may also investigate a health professional or impose sanctions (for example temporary withdrawal of their licence). The employers must create conditions for further education of their employees while professional organizations must participate in educational activities and quality assurance programmes. 562634-EPP-1-2015-IT-EPPKA2-SSA

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European directives emphasise the importance of lifetime education of healthcare professionals, for the obvious reason, which is the prevention of potential harming of the patient. They lay down the duty of member states to provide continuing education of healthcare professionals and leave the fulfilment of this duty in their responsibility. This obligation appears in conceptual and strategic materials and legal norms of the Slovak Republic as an obligation of one of the member states of the European Union. According to the Act No. 578/2004 Coll. on healthcare providers, lifetime education is healthcare professional’s duty. Continuing education is characterized as a continuous renewal and maintenance of achieved specialized professional competence for execution of medical profession in compliance with the relevant fields during the entire time of the execution of relevant health profession. The following professionals with obligatory education are working in HOME NURSING [Genet et al, 2013]: • •

Nurse: performing injections, infusion, wound care, ulcer treatment, etc.; they got bachelor or masters education. Health care assistant: supervised by a nurse, providing elementary nursing, assisting in diagnostics, prevention and administration; they attend four years basic vocational training.

NURSES The educational curriculums for nurses and health care assistants have been regulated nationally (by Government Regulation 296/2010) and the educational programmes must be accredited by the Ministry. For citizens of the Slovak Republic that have never before gained a nurse qualification, under the new legislation to qualify as a nurse requires [Beňušová K. 2004]. • •

a higher vocational education as a trained general nurse in a relevant secondary health school in the Slovak Republic or a level I. university education in a bachelor study program in nursing (Bc.).

Both these programs have to comply with the EU directive stating that the nursing studies have to take at least three years when studying full time and include 4600 hours, which are equally split into theoretical and practical training. Since the nurse training similarly to the dental practitioner training was considerably different to EU expectations before the entry of the Slovak Republic into EU on the 1st may 2004, the Slovak Republic had to gradually dampen the full secondary vocational training in nursing and leave only a higher vocational education. Only the higher vocational education in general nursing in secondary health schools was rated by the evaluation mission of the European commission TAIEX in 2002 as fully compatible with the expectations of EU. The evaluation mission reproached the nurse training in the full secondary vocational education in Slovak secondary medical schools for starting the training for such an arduous profession already before the nurses seventeenth year of age, which it considered unacceptable. In the Accession Treaty of the Slovak Republic into the European Union nurse training gained or nurse training started within the territory of Slovak Republic before the entry of the Slovak Republic into EU in nonconforming program classed as a training, based on which the nurse continues in this medical profession 562634-EPP-1-2015-IT-EPPKA2-SSA

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and all member states will consider her training equivalent, if she worked in the Slovak Republic in general nursing for at least three years within the last five years. Considering this, it follows that nurses, who gained their training according to present regulations, can continue working in the Slovak Republic in specialized nursing work in present scope without having to supplement their education with a university nursing degree (for details refer to temporary provisions of the Regulation of the Government No.156/2002 Coll. later Regulation of the Government No. 212/2004 Coll. and then Regulation of the Government No. 742/2004 Coll. about the qualifications for medical profession.) [Beňušová K. 2004]. The newly determined expectations for nursing qualifications therefore only apply to citizens that never previously worked as nurses and after the entry of the Slovak Republic into EU have decided or will decide to train for this medical profession within our territory. The Slovak Chamber of Nurses and Midwives (www.sksapa.sk) issues a licence to work in a health profession nurse to citizen who gained or were admitted nursing qualifications, and have applied for this licence. Should the nurse intends to under her own name and under own responsibility, run their own agency for home nursing care or nursing home, its vital to submit the licence issued by the chamber to the relevant (according to the place of the practice) regional authority (best to the nurse of regional authority) with the application for the running one of the above mentioned healthcare facilities. The nurse provides basic and specialized nursing care using the method of nursing process. The scope of nursing practice is stipulated by the Regulation of the Ministry of Health of the Slovak Republic No. 364/2005 Coll., which establishes the scope of nursing practice provided by nurse independently or cooperating with a doctor and the scope of nursing practice provided by midwife independently or with cooperation with a doctor. No detailed information about Slovak nurses competencies have been retrieved. HEALTH CARE ASSISTANT The educational curriculums for health care assistants have been regulated nationally (by Government Regulation 296/2010) and the educational programmes must be accredited by the Ministry. They provide basic nursing care under the specialized supervision of the nurse and cooperate by specialized and nursing care in healthcare using the method of nursing process and participate in specialized administrative and documentation work of healthcare providers. This study takes place in relevant secondary health schools in the Slovak Republic in a form of full higher specialized vocational training and the medical assistant is trained to be able to cooperate in basic nursing activities with the nurse. Considering relevant EU directives on minimal requirements for the content of nurse training, so far it is not assumed that the medical assistant could take over and independently execute some of the competencies of the nurse, as for instance blood taking for tests, cooperation by blood transfusion, catheter insertion in women etc., but he should cooperate with the nurse in complete hygienic care, the prevention of bed sores, checking the drinking schedule etc. Establishment of this new study will help nurses with some of their present activities. No detailed information about Slovak health care assistant competencies have been retrieved. 562634-EPP-1-2015-IT-EPPKA2-SSA

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Among long-term carers there are those educated for the job and those without such specific training. A figure named CARER provides PERSONAL CARE: he/she attends full secondary vocational training with a focus on home care (nursing) and health care or accredited course (220 hours) for carers [Genet et al, 2013]. Most carers employed by municipality are employed with a salary, but some are employed through a work performance agreement (paid for a certain number of services to be provided instead of hours) [Genet et al, 2013]. FAMILY ASSISTANTS provide DOMESTIC AID, performing activities such as: shopping; accompanying the older adult to a doctor; appointment; getting medical prescriptions from pharmacies; help in the farmyard, care of animals, wood chopping; housekeeping (cleaning windows, tidying, food preserving in summer/autumn); mediation of social contact with peers; going for a walk, companionship, supervision of seniors during the absence of their family members; ensuring and facilitating contact with authorities (social insurance, health insurance, post office, ministries); visiting elderly person living alone in hospital [Szüdi et al., 2016]. In 2010 the number of personal assistants was 9,340 (from that 212 were family members) and the number of untrained informal family carers was 56,434. No detailed information about Slovak Carer and Family Assistant competencies have been retrieved.

32.2.1 References Beňušová K. (2004). Education of healthcare professionals in the Slovak Republic, Approved on November 28th, 2005 by the Minister of Healhcare of the Slovak Republic. www.health.gov.sk/ Genet, N., Boerma, W., Kroneman, M., Hutchinson, A., & Saltman, R.B. (2013). Home care across Europe. Copenhagen: WHO, Regional Office for Europe (on behalf of the European Observatory on Health Systems and Policies) http://www.nivel.nl/sites/default/files/bestanden/Home-care-across-Europe-case-studies.pdf Lezovic, M., Raucinova, M., Kovac, A., Dzundova, Z.,Moricova, S., & Kovac, R. The position of home care in the system of long-term care in Slovakia. Lekarsky obzor 56[12], 514–517. 2007. Lezovic M., Taragelova B., Beresova M. (2011). Home care in Slovakia. Bratisl Lek Listy 2011-112 (9), pp.488490. Radvanský M. & Páleník V.(2010). The Long-Term Care System For The Elderly In Slovakia. European Network of Economic Policy Research Institutes (ENEPRI) RESEARCH REPORT NO. 86, 2010. ANCIEN Project website http://www.ancien-longtermcare.eu/node/27 Szalay T, Pažitný P, Szalayová A., Frisová S., Morvay K., Petrovič M., van Ginneken E., Slovakia: Health System Review, Published by Observatory, ISSN 1817–6127 Vol. 13 No. 2, April 2011 http://www.hpi.sk/en/category/health-system-in-slovakia/ Szüdi G., Kováčová J. & Konečný S. (2016). Transformation of Social Care Services for the Elderly in Slovakia, Journal of Social Service. Research, Research, 42:2, 199-217, DOI: 10.1080/01488376.2015.1129016

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33 OLDER PERSONS HOMECARE IN SWEDEN Legislation relating to the provision of home care services The Ministry of Health and Social Affairs in Sweden is responsible for general planning, guidance and supervision aimed at older people. The overall policy is that people have the possibility to live independently and safely in their own homes as long as they wish with support and home-care if needed. The targets are established by the Swedish Government and Parliament. The care of older people, which includes the care of people with dementia, is regulated by three laws. Each law regulates in a different way what the public sector can expect in relation to the individual and what kind of rights the individual has. The laws are as follows: • • •

the Law of Health and Medical Services (HSL) 1982:763; the New Social Service Legislation (SOL) SFS 2002:453 (which came into force on 1 January 2002); and the Law of Support and Service to Certain Persons with Handicap (LSS) 1994 which is a law of rights and carefully specifies the obligations of municipalities and county councils as well as individual rights. Only younger people, under 65 years, with dementia have a right to receive help from a personal assistant instead of home care.

The HSL includes an obligation of health service authorities to provide home care services if the needs cannot be met in any other way. Much of the care is carried out by families (informal caregivers). However, there is no statutory obligation for children to care for or financially support their parents. In the Social Service Legislation there are rules which state that the municipalities shall give those who need it, i.e. elderly people and those with disabilities, the kind of support they need which among other things includes home care services. There is no specific reference made to people with dementia. Moreover, there is no national, legally binding definition of dependency in Sweden. People with dementia are covered by the categories “elderly” and “people with disability”. Home care includes medical, rehabilitation and social work which a person may need at home. According to the SOL, municipalities should support relatives. An important means of support for people with dementia, to enable them to live at home, is day-care which can provide stimulation and ensure the safety of people with dementia, as well as providing relief for the relatives. However, day-care is not compulsory. The municipalities are independently responsible for providing social and home care. Social legislation provides a legal framework which gives the municipalities freedom to develop the law according to local conditions and political decisions. They can therefore interpret their obligations differently. Many municipalities have developed their own informal guidelines on service provision with the result that in some areas, for example, elderly people who only need help with cleaning are no longer eligible for home-help. Some have introduced means testing for some services. (Thorslund et al., 2001) Organisation and financing of home care services In Sweden, the welfare of the elderly is divided between three levels of government: • •

at national level: the Parliament/Government (responsible for establishing policy aims and directives by means of legislation and economic steering measures) at regional level: the county councils (responsible for the provision of medical and health care)

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•

at local level: the municipalities (responsible for meeting the social services and housing needs of the elderly) (Regeringskansliet, 2002)

In 1992, the Swedish government implemented the Community Care Reform (known as the Ädelreform) which involved the decentralisation of responsibility and resources for the care of the elderly from regional to local governments. (Regeringskansliet, 2002) Half of the municipalities, 144 of 290, in the country have now taken over responsibility for health and medical care in ordinary living. In the other municipalities, the county councils are responsible. The municipalities are responsible for organising service and home care for their inhabitants. They can provide services themselves or they can buy from private providers. The local authorities are obliged to have insight into and keep control of both their own and private type of care. Support from voluntary organisations is limited. The municipalities are responsible for providing assistive devices for the elderly. Since an increasing number of people with dementia remain at home in their usual environment for an increasingly long period of time during the course of the disease, specially developed care and support measures are needed that target them and their close relatives. In a number of municipalities, there are clear plans and strategies for how the municipalities can provide individual adapted care for people with dementia. In many other areas, both knowledge regarding the needs of people with dementia and their relatives and the activities and resources offered to meet these needs are insufficient. The fees charged for home help are determined by the amount of help needed and a person’s income. Nevertheless, people receiving home care only pay a fraction of the actual cost. Also, since 1 July 2002, there has been a maximum fee for elderly patients resident in the municipalities. (Regeringskansliet, 2002) The provision of services is based on an assessment of the person’s housing, services and care needs. This is usually carried out by a municipal care manager, or as is often the case for elderly people, by an interdisciplinary care planning team (Johansson, 2004). Kinds of home care services available Entitlement to aid, insofar as this concerns the care of elderly people, includes amongst other things help in the home with services and personal care if the needs cannot be satisfied in other ways. The type of home care provided can be divided into different services which involve practical help with running of the home, cleaning and laundry, help with purchases and other important errands, as well as cooking and help eating. Help with care means personal help with tasks which are needed in order to satisfy the person’s physical, mental and social needs. It may be help with eating or drinking, getting dressed and moving, help with personal hygiene, activities to break isolation, measures to ensure that the person feels safe and secure at home, or a safety-alarm (which only people with mild dementia can use). It is possible to get home care and medical care every day of the week, in the evening and at night. In 1997, 28 percent of those receiving home help received it in the evenings and at night. In addition to home help, other municipal services for the elderly include transportation services, foot care, meals on wheels, security alarms, housing adaptations and disability support, etc. (Regeringskansliet, 2002). Consultation with people with dementia and carers 562634-EPP-1-2015-IT-EPPKA2-SSA

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§29 of the Law of Health and Medical Services HSL and chapter 3, §5 of the New Social Legislation SoL, states that home care services should be organised in consultation with the people and relatives who are asking for a special kind of assistance. A decision made in accordance with the social law can be appealed if the decision is wholly or partially against the person’s wishes. In 2002, the Government decided to set up a working group to compile the knowledge available about the situation of people with dementia and their relatives. Its objective was to try to provide a comprehensive overview of the current situation. The group has presented a national view of how dementia care has evolved in Sweden during recent years and the areas that it is important to prioritise and develop in the next few years. This report entitled “På väg mot en god demensvård” (On the way towards good dementia care) was published by the Ministry of Health and Social Affairs in 2003. This report has led to a number of different projects in the Municipalities and County Councils. There are no national facts about users’ satisfaction but many local studies have been done which show that people are generally satisfied with home care. General satisfaction is however a blunt measure for services and care. The failings become much clearer with specific questions. Another problem is that many people cannot answer the questions because of their disease. Often the questionnaire or interview is answered by the relative even though users and relatives’ opinions about care often differ. In 2003, the Swedish Dementia Association published an extensive study of the situation of caregivers. In studies where users have been asked how important a certain fact is, the answer is very often that having the same member of staff is important for their safety. A common experience is that staff is in a hurry. There is no time to talk and be together socially. Questions which are given the highest evaluation are those concerning treatment and accessibility. It is also important to be aware of the needs of people with dementia and their relatives and to understand the experience and needs of people with dementia in particular. In some communities, specially organised home-care for people with dementia has been started. Support for people with dementia in their own homes varies greatly from one community to the next. In the inquiry into dementia in 2002, 9% of the communities said that they had specially arranged home care for people with dementia. In certain cases, there is specific planning and a strategy on how the communities should treat and give individually designed care to people with dementia. Elsewhere, knowledge about people with dementia and their relatives is insufficient. However, a great deal of education/training for staff working with people with dementia has been organised. Awareness about the importance for staff providing care and support to persons with dementia to have the requisite knowledge has increased. They have to know how to behave towards people with dementia, how to stimulate them, what attitude to have when handling challenging behaviour and how to make the most of a person’s remaining capacity.

33.1.1 References Information provided by Inge Ploby Johansson, L. (2004), National Background Report for Sweden, EUROFAMCARE.http://www.uke.unihamburg.de/extern/eurofamcare/documents/nabare_sweden_rc1_a4.pdf

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Regieringskansliet/Socialdepartementet (2002), Answer to questionnaire on health and long-term care of the Elderly – Sweden, European Commission, (http://europa.eu.int/comm/employment_social/social_protection/docs/sv_healthreply_en.pdf) Thorslund, M. et al. (2001), Care for elderly people in Sweden. In Aging: Weisstub, D.N. et al.) (Eds.), Caring for our Elders, Kluwer Academic Publishers

34 OLDER PERSONS HOMECARE IN UK 34.1Introduction to older persons homecare service in UK In the United Kingdom healthcare and homecare services are perfectly designed to assist the needs of the elderly people in their country. It is provided either by NHS or the local Council (or sometimes both). There are several well based private care providers (AgeUK, Find Me good Care website, etc.) and volunteering groups (AgeUK or the Royal Voluntary Service), and charity organizations well organized. There are several regulatory bodies to hold up a good evolution of the care providers (Regulatory Authorities for Care Homes, Extra Care Housing & Adult Day Care Centers http://www.carehome.co.uk/regulatoryauthorities/ ) and inspection (Care Quality Com-mission (CQC) http://www.cqc.org.uk/content/regulatedactivities ) and any information is easily located in the internet. The CQC is the national independent regulator of all health and social care services in England. At present they are working on 2016-2021 strategy to make safe, effective, compassionate, high-quality care and encourage care services to improve. They monitor, inspect and regulate services and produce reports in regard. (In Wales: the Care and Social Services Inspectorate Wales). Furthermore, U.K. has established a Local Government Ombudsman, the Adult Social Services Safeguarding team, and the Equality Advisory and Support Service to investigate any possible complaint or misunderstanding. At the first stage of contact, a social care professional from the social services department in all local councils is in charge of assessment. This assessor (free of charge) will come to the older person´s home and will not only consider physical safety but also emotional and social aspects of his/her life. Clients are classified as having needs in one of four categories: low, moderate, substantial or critical. They will decide together with the elderly the best kind of care or support most adequate to meet their needs. Whether the elderly will have to contribute for these services or the local council will take charge of their costs depends on the income, capital and savings of each person. There is a national threshold for eligibility. The council can provide its own services or give a direct payment to the needed person to fund the services he/she will receive. There are upper and lower limits for help. Over £23,250 they will have to pay their own fees, named Self-funder; under £14,250 the city council will fund the costs but the elderly will have to contribute with their pension. (In Wales £24,000 upper limit and there is now lower limit). Nevertheless, the elderly person is ensured by a Personal Expenses Allowance. There is a wide range of home care services: residential care; community cares services; NHS continuing healthcare; short-term respite services; long-term home care services; occupational therapists; nurses; volunteers; handy-person; TaxiCard or Dile-a-Ride services for disabled persons; chiropodists; specialist equipment and adaptations for daily living like walking frames, handrails, bath seats, etc. (if they cost less that £ 1,000 they are free of charge); Telecare services (to remind tasks, medication alerts, personal emergency alarms, etc.); personal care services (getting dressed, bathing, eating & drinking, getting around or needing

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someone to watch over the elderly for a few hours, …). The U.K. Care Act 2014 complies rights and duties of care givers. As for nursing needs, as of November 2014, there was a lack of 20,000 full-time posts in the U.K. Hospitals are hiring hundreds of nurses, even not knowing the English language (mostly from Portugal and Spain, because they are highly qualified and experienced, low-paid in their home country or all the way, into unemployment). As for Qualification Framework in the U.K., educational pathway is as follows: •

•

•

Care Certificate (set of standards developed for non-regulated workers that links to National Occupational Standards: Understanding your roll; Personal development; Duty of care; Equality and diversity; Work in a person centered way; Communication; Privacy and dignity; Fluids and nutrition; Awareness of mental health; Dementia and learning disabilities; Safeguarding children; Basic life support; Health and safety; Handling information; Infection prevention and control. Apprenticeships (work-based learning program leading to nationally recognized qualifications of any age). Currently there are three levels of social care Apprenticeships (Intermediate Apprenticeship in Health and Social Care – Level 2; Advanced Apprenticeships in Health and Social Care – Level 3; Higher Apprenticeships in Health and Social Care – Care Leadership and Management – Level 5). The core pathway is based on the Level 5 Diploma. As well as taking the core pathway, the option of Higher Education – Level 5 is available. o Level 2 HSC Diploma: Apprentice working in domiciliary care; community learning disability; residential homes; adult residential care; supported housing providing specialist care; end of life care. o Level 3 HSC Diploma: Apprentice working for learning disability service; personal assistants; in residential homes; sensory service; community learning disability teams; with individuals with learning disabilities; brokerage support service; mental health services; working as care worker in adult social care setting role as end of life care; reablement role in care home or community settings; working in supervisory role for individuals with dementia; working as infection prevention and lead in a care home setting; in autism services. o Level 5 Diploma: for leadership for health and social care, and children and young people´s services for Adults residential management pathway; for Advanced practice pathway and Commissioning procurement and contracting for care services). o Level 7 Diploma in Commissioning procurement and contracting for care services. The requirements of the European Directives 77/453/EEC and 89/595/EEC apply to all nurses undertaking programs for adult nursing. The Nursing and Midwifery Council (NMC) registers all qualified nurses in the U.K. Educational programs are designed in accordance with EU agreements and comprise a Common Foundation Program (CFP) of 12 months for students aiming to enter all branches; this is followed by a branch program of 2 years in adult nursing, mental health nursing, learning disabilities nursing or children's nursing (for full-time programs). The balance of learning and teaching activities is 50% practice and 50% theory in both CFP and branch programs.

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Actors in home care: - Department of Health of England - Stragetic Health Authorities - Care Quality Commission - Local Authorities - Primary Care Trusts - Home Nursing and Domiciliary Care provider agencies - Local Housing providers (“Extra-care” housing) - Skills for Care. (Company that develops educational and practical skills frameworks and assist training of overall non-professional social care workforce) - Voluntary and Charitable (third Sector) organizations

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34.2HHCP involved in older persons homecare service in UK: roles and competences OCCUPATION - HCCP

ROLE

KNOWLEDGE

SKILLS

COMPETENCIES

(SET OF ACTIVITIES)

know what - theoretical and/or factual knowledge

know how to do - SKILLS as cognitive

know how to be

To know basics on how to do housework.

To keep hygienic conditions of the customer´s personal environment.

To use cleaning products in a proper way

To do daily housework

To have a positive attitude if the elderly person is untidy

To remove risks on not keeping the house clean

To evaluate risks while keeping the hygiene of the home environment

HHCP1 Domestic Staff (Level 0) No qualification required although Common Induction Standards (CIS) are encouraged. Care certificate will replace CIS diploma. Environmental monitoring

To know basics of hygiene in home environment (cleaning, food etc.)

To take action to reduce the risks of unclean environment.

Health monitoring

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To know basics physical and mental health conditions

To report any health risk (to whom, how, with what times)

To manage the situation while health professionals arrive to take over.

To take action to reduce the risks

To be patient with mentally or physically disabled

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To know basic ways of communicating risk conditions To have basic ideas about domestic economy

To report any health risk (to To communicate correctly whom, how and when) those health risks to the elderly person and/or other personnel involved To do grocery shopping

To know basics of nutrition

Activities of daily living support

Values and principals

HHCP2 Day care worker, homecare worker, personal assistant, other staff in caring roles, support workers and volunteers. National Vocational Qualification

To know basics on how to deliver meal services To have a basic knowledge regarding physical and mental conditions of older adults during accompaniment (falls risk assessment) To have a basic knowledge of socialization process To have basic knowledge of disrespectful or inappropriate circumstances

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To follow instructions on how to deliver meals correctly

To be motived to give advices about food to buy on the basis of economic availability and food needs To be able to care for meal services maintenance

To accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To promote socialization

Ability to evaluate and assess a socialization process

To report unethical situations (to whom, how and when)

Ability to evaluate tampering by others

To take action to reduce unethical situations To report environmental risks (to whom, how, with what times)

To reinforce equality, diversity and transcultural approaches To guide ways of avoiding risks on home environment safety

To report hygiene risks (to whom, how, with what times)

To evaluate appropriately the risks of unhygienic home

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(NVQ) (Level 2 & 3)

food etc.)

environment

To take action to reduce the risks

Health monitoring

To report any health risk (to To know the main whom, how, with what times) indicators of risky conditions for physical and mental health (sudden To take action to reduce the illness, accidents, spread of risks infection, etc.)

To properly evaluate a mental and physical risk in home environment To have a patient attitude in order to develop good habits

To interact for healthy behaviors in medical prescriptions To know healthcare To guide the older adults on To motivate the usefulness / organizations and services principals and existing services necessity of activation of a for older adults in the area that can make life service. easier To know how to support To provide individuals with To ask for help from individuals according to information to enable them to appropriate personnel when their personal choose the way they want to not confident or skilled in the care/support plan be supported role to carry out. To know how to activate To maintain social connection To have communication skills formal and informal with medical personnel, social and involvement of the older support networks to worker, neighbors and adults in the interactions. stimulate active and volunteers healthy lifestyle To know the role of the To be able to respect social To encourage the elderly to social worker workers´ indications communicate with the To know how to help in medication adhesion

Equipe working

To interact with the elderly person in order to reinforce self-protection

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network

Administrative support

To know the values and principles of adult social care To know about administrative practices related to aging management

To know how to keep privacy of customer´s physical/ mental conditions To support in complying fiscal practices and other practices relating to the older adults

Reflect on holistic work practices

To know the importance of privacy

To keep privacy about customer´s reports

To respect the elderly person´s decision

Domestic economy Basic knowledge of nutrition

Activities of daily living support

Grocery shopping

To know basics on how to deliver meal services To Know physical and mental conditions of older adults during accompaniment (falls risk assessment) To know how to identify, respond to and escalate changes to physical, social and emotional needs To have basic knowledge of Socialization process

To follow instructions on how to deliver meals correctly

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To foster positive attitudes in fulfilling public rules

Assessing foods to buy on the basis of economic availability and food needs To be able to care for meal services maintenance

To Accompany when going out

Ability to overhaul the older adults conditions before and during the accompaniment

To report changes to the correct professional , (to whom, when and where)

To motivate readaptation of the elderly person after changes

To know how to evaluate and assess a socialization process

To have the ability to promote socialization

To recognize potential signs of different forms of abuse

To support and challenge unsafe practices

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and protection from abuse

HHCP3- Therapists Chair based exercise qualification (Level 2)

To know the barriers to communication (nonverbal communication, importance of active listening, etc.) To know basics on physical anatomy Activities for chair based exercise

HHCP4 -Specialist in Older adults with dementia (Level 2 & 3)

Activities for older adults with dementia

HHCP5 - Specialist in Diabetes (Level 2 & 3)

Activities for older adults with diabetes

To report abuse (to whom, when and where) To know how to avoid barriers to communication To know how to provide chair based exercise for frailer older adults and disabled adults

To establish ways to communicate with the individual. (Establish signs, gestures, marks, communication boards, etc.) To have the ability of identifying erroneous treatments.

To know the values and principles of adult social care To know how to be aware of dementia

To know how to keep privacy of customer´s physical/mental conditions To report risks of dementia in older people (to whom, when and where)

To have the ability of approaching dementia without hurting sensibilities

To know the factors that can influence communication and interaction with individuals who have dementia

To know how to cope with individuals with dementia

To treat individuals with dementia under equal rights

To know the values and principles of adult social care To know how to be aware of older people with diabetes To know the importance of privacy

To know how to keep privacy of customer´s physical/mental conditions To know to report a risk of diabetes (to whom, when and where) To keep privacy about customer´s reports

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Reflect on own work practices

To encourage the elderly person to entitle respect for his/her personal values To know how to prevent diabetes and/or early detection To encourage the elderly person to entitle respect for

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his/her personal values HHCP6 - Specialist in Awareness of End of Life (Level 2, 3 & 5)

HHCP7 - Specialist in Seated recreational Physical Activities (Level 2) and Stroke Care management (Level 3) HHCP8 NVQ Health and Social Care (level 4) and Registered Managers Award (Level 4) aimed at managers of care services (MIS Award). Leadership for Health and Social Care (Level 5)

Activities to support individuals during the last days of life

To know how to manage symptoms in end of life care To know the importance of privacy

Activities concerned with To know basics on physical specified physical/mental injuries anatomy The roll is the same as HHCP2 mainly to develop broader skills and knowledge as: Community Care/Support Officer, Care Assessment Officer, Social Services Officer, Occupational Therapy Assistant, Physiotherapy Assistant, Independence Support Assistant, Telecare Assistant, Social Care Assessor, Community Care Assessment Officer, Social Care Assistant, Brokerage worker, Occupational Assessment Officer, Rehabilitation and Re-ablement

To understand advance care planning

To know how to support individuals with loss and grief before death and/or specific communication needs

To keep privacy about customer´s reports To know how to cope with specific health injuries

To provide positive feedback to avoid doldrums or depressions

To know the aims of each service provided

To evaluate correctly the service provided

To take an active part in profitable teamwork

To know the needs of each elderly person under charge

To organize the best plan for each individual

To reflect on own work practices

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Assistant, Re-ablement support worker/officer, and Assistive Technology Co-ordinator/officer To know all the services that can be provided

To fit services with specific needs

To be an active listener to carers remarks as well as to customers´ complaints

http://www.skillsforcare.org.uk/Document-library/Qualifications-and-Apprenticeships/Adult-social-care-qualifications/Guide-to-qualifications-and-standards-inadult-social-care-201415.pdf

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35 OLDER PERSONS HOMECARE IN SWITZERLAND 35.1Introduction to older persons homecare service in Switzerland Homecare in Switzerland is not officially regulated. Swiss Federal Law on Health -1996, 101bis articledetermines that the Swiss government must subsidize homecare services for elderly, but it gives cantons most responsibilities to plan and provide these homecare services. The following demographic statistics are from Ireland's Central Statistics Office (CSO), Eurostat and the CIA World Factbook.Population:061,516 Age structure 65 years and over: 17.5% (male 616,009/female 798,419) (2014 est.) Median age

total: 42 years a) male: 41 years b) female: 42.9 years (2014 est.)

Sex ratio 65 years and over: 0.76 male(s)/female total population: 0.97 male(s)/female (2014 est.) Life expectancy at birth total population: 82.39 years a) male: 80.1 years b) female: 84.81 years (2014 est.)

Figure 27: Population in Switzerland - 2014

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In Switzerland, there is a balanced rate of male and female older people taking care of elderly. These care providers are not considered workers with a very high status. The payment for homecare, even though the State bears subsidiary liability, is done by elderly and their families. Whenever these are unable then the State intervenes. At present there is a lack of political concern about economic and social aspects aimed at normalizing homecare services for elderly people in the country. The payment to care providers is done in a variety of ways, using several means of payment, such as copay depending on the annual income of the elderly, prevailing the private homecare provider. At present there is a debate as to which is the adequate financial assistance of the initiatives in favor of elderly care, promoting strategies to increase the involvement of relatives in the homecare provision. Assistance nurse, home help assistance, personal assistant, nurses, home help officer, and informal caregivers HHCP are involved in older persons homecare service . Nurses in Switzerland have basic knowledge of health issues and of prevention, diagnostic, therapeutic, palliative and rehabilitation measures; they also have abilities on clinic reasoning, they are able to search and integrate information for their professional practice, they can give advice on health issues to patients. As for their capabilities, they are able to take responsibilities for their actions and respect their limitations, are autonomous in their work, are able to solve problems, communicate and participate in development, promote health and prevent illnesses.

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35.2HHCP involved in older persons homecare service in Switzerland: roles and competences Occupation

EQF

Role

Knowledge

Skills

COMPETENCIES

know what - theoretical

know how to do - SKILLS as

know how to be -.

and/or factual knowledge

cognitive and practical Responsibility

Assistant nurse

Home help assistant

Personal assistant

Nurse

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3-4 Three year upper secondary school education .

3-4 Three year upper secondary school education

3-4

6

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Cooperation Management Work environment Provide home help services i.e. domestic aid and personal care (bathing, dressing, etc.). Activities such as socializing or going for a walk. Short course focused on Provide home help services the role of being a personal i.e. domestic aid and assistant. personal care (bathing, dressing, etc.). Often the person has a three year upper secondary Activities such as socializing school education. or going for a walk Know the legal bases and Know how to develop a the priorities of the Health career being respectful with Policy of the Swiss System legal grounds with efficacy. of Health on care and social Adequate medicine protection as well as administration. 369 of 418

Capability of playing a role within the health system which guarantees the quality of attention and the best practice.

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direction principles and its limits. Instruction in scientific search methods within the Scientific knowledge to be domain of health, applying able to take preventive, evidence based practice. diagnostic, therapeutic, palliative and rehab Keeping clinical reasoning measures. and their attitude to develop the necessary measures Knowledge of depending on the type of determinants that keep occupation and support. and favor the health of individuals and population, Being capable of and those capable of participating in the search inhibiting the measures and integration of relevant which contribute to and concluding information improving the quality of for the professional practice life. Giving advice to patients and companions on health issues based in updated scientific knowledge and in ethical principles.

Capability of being responsible of own actions and assuming own limitations. Capability of being autonomous within the professional activity. Capacity of active search of an inter-profesional activity and cooperation with Health System. Capacity to develop understanding during assistance and, when necessary, to problem solving. Ability to communicate with groups of patients and professionals about specific care. Ability to participate in the development of the promotion of health and illness prevention.

Home help officer

6-7 Three

Including education in year management and service assessment.

Responsible for the assessment of home help service.

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education

at

university level.

Has to make sure that indicated home help service is being provided Respite via short-term care. Respite via day activities. Respite in the own home. Individual talks.

Informal caregivers

1-2

Family support group and centres. Educations and recreation. Well-being activities are available for informal carer (ibid).

35.2.1 References Danielsson M. Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study. BMC Nurs [Internet]. 2014; Recuperado a partir de: http://bmcnurs.biomedcentral.com/articles/10.1186/s12912-014-0039-5 Nilsson G. The subject pedagogy from theory to practice - the newly registered nurses view [Internet]. Lund University; 2008. Retrieved from: https://www.google.es/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwjJyrrCsurLAhUBfRoKHfqVAJoQFghJMAU&url=http%3A%2F %2Fwww.med.lu.se%2Fcontent%2Fdownload%2F77088%2F549223%2Ffile%2FProjektBodilIvarsson2.pdf&usg=AFQjCNGuhz_n1M39K3XVKT8MXEVRCJCbw&sig2=rvkhJcMIg8bEARQGNFh3fw&bvm=bv.118353311,d.bGs Final project skills Professions HES health. Appendix I. http://www.hes-so.ch/data/documents/projet-competences-finales-professions-sante-HES-annexe-718.pdf

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36 OLDER PERSONS HOMECARE IN NORWAY 36.1Introduction to older persons homecare service in Norway Legislation relating to home care services People in Norway are not legally obliged to provide care for their parents. National legislation obliges the health and social services to provide home care services to those who need them. However, there is no specific reference to people with dementia. Act no. 66 of 19 November 1982 on Municipal Health Services describes the duties of the health services as follows: 1.

The promotion of health and prevention of illness, injuries and physical defects

2.

Diagnosis and treatment of illness, injuries or physical defects.

3.

Medical rehabilitation.

4.

Nursing and care outside health institutions.

The municipalities have to provide the following services: 1.

General medical practices

2.

Physiotherapy

3.

Nursing, including home care services.

The municipality shall plan, organise and provide the services regulated in the law. The people receiving care shall: • • • • • • • • • • • •

feel safe, respected and have a foreseeable situation be able to take care of themselves as long as possible have their basic physical needs taken care of receive adequate help with meals and have enough time to eat in peace receive help with personal hygiene and bodily functions receive help, if needed, to dress and undress be able to follow the natural rhythm of the day, avoiding unwanted stays in bed have the possibility for privacy and self-determination be able to have social contact be able to participate in suitable activities both indoors and out of doors have necessary medical check-ups, treatment, rehabilitation and care have necessary dental check-ups and treatment (Axel Wannag, 2000).

Act no. 81 of 13 December 1991 on Social Services, Chapter 1, Section 1-1, states that the purpose of the Act is:

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to promote financial and social security, to improve the living conditions of disadvantaged persons, to contribute to greater social equality and to prevent social problems. to ensure that each individual has the possibility to lead an independent, active and meaningful life together with others.

Chapter 4, Section 4-1 describes the aims of social services as being to provide information, advice and guidance in order to resolve or prevent social problems. If the social services are unable to provide such assistance, they must, if possible, make sure that others do. The Social Services consist of (section 4-2 in the Act): The Social Services consist of (section 4-2 in the Act): • • • • •

practical assistance and training to people who need it due to illness, disability, age or for other reasons short-term care in order to relieve carers with a particularly heavy burden support to individuals and families who need it due to disability, age or social problems institutional care for those who need it due to disability, age or other reasons financial aid to carers with a particularly heavy burden.

Organisation and funding of home care services Home care services for the elderly and disabled are organised, managed and financed by the municipalities. Users may have to pay a fee for some of these services. The size of the fee varies from one municipality to the next. Most of the municipalities (80%) offer services 24 hours a day. Approximately 155,000 people received home care services in 1999 (European Observatory on Health Care Systems, 2002). "Report No. 20 to the Parliament (1996-97), Plan of Action for Care of the Elderly; Security - Respect - Quality" is a four-year plan of action for nursing and care services run by the local authorities. The main aim of this plan was to develop local services for nursing and care by: aim of this plan was to develop local services for nursing and care by: • • •

providing services that ensure the elderly a secure and, as far as possible, a fulfilling and independent life; enabling the elderly to live in their own homes as long as possible; making sure that the services have sufficient capacity

This was achieved through general guidelines including: • • • •

ensuring high-quality nursing and home care services developing an integrated, flexible range of services providing equal facilities nationwide, independent of a person’s place of residence, income or resources ensuring greater participation and freedom of choice to service users.

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According to Ingebretsen and Eriksen (2004), the goals of this action plan, which include the strengthening of home-based care, have to a large extent been achieved, albeit with considerable regional variations. This has led to more home-based care. It should be noted, however, that Norway is a very sparsely populated country with great variation between municipalities in terms of socioeconomic structure, population etc. The provision of services is based on a person’s needs regardless of whether they live alone or with a spouse/family. In this way, the assessment is based on the condition of the person requiring assistance and not on the ability or willingness of relatives to provide services or meet needs. In practice, however, elderly people living alone are sometimes given priority. (Ingebretsen and Eriksen, 2004). In June 1998, the Norwegian parliament adopted the National Programme for Mental Health. Implementation of this programme started in 1999 and will run until 2008. A document entitled “Mental Health Services in Norway – prevention, treatment, care” produced by the Norwegian Ministry of Health and Care Services can be found at: http://odin.dep.no/filarkiv/233840/MentalHealthWeb.pdf Kinds of home care services available Home care services typically include: • • • • • • • • •

Leisure activities Assistance handling personal finances Ensuring that medication is taken Housework Cooking Shopping Personal hygiene Getting dressed and undressed Technical aids

Day care centres exist but are not statutory. Rehabilitation Lately, there has been an interest in the project ”every – day – rebahilitation”, which some communes have adoptes from rehabilitation – prosjects in Denmark and Sweeden. This impies a stronger emphazis on personell with rehabilitation – skills, and it gives the whole personell – group involved an opportunity to work whith the patients in a slightly different way. It also empowers the patients, as one of the core aim is to enable the patienst to reach their own, selfdefined goals of rehabilitation in the every – day life. Recruitment challenges The shortage in health and social personnel in Norway is being met in many ways, some of which the trade unions are highly sceptical to. Stong, multinational recruitment companies bring in people from abroad. The salaries, pensions ( if they have any) and working conditions are some times below the standards that are set in the central agreements and the conditions, for example working hours, are often way beyond the limits set by our Working Enwiroment Act. Norway is dependant on these very able and hard working people, also within the health and care sector. It is a great shame that they are often offered working conditions and places

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to live, that are below standards and regulations, and the trade unions should intensify our efforts to set this straight. There are a large number of enrolled nurses in the age group of 55+, and the recruitment of young people is low. In addition, Norway expects a high rise of old people in the near future. We need to encourage young people to choose the health sector. The Collaboration reform There has been a lot of discussions related to a major reform move that was implemented some years ago. The aim is, amongst other beneficial goals, to ease off the pressure in the health services, especially within the hospital services. The reform draws up some general lines; • •

• •

Preventive actions; less sick people, less pressure. To be able to prevent; all sectors must collaborate. More (even more) responsibility to the local municipals, increased medical care in the local community, less entries to hospitals, quicker (even quicker) transfer back home from hospitals for non-surgical patients ( of whom many are the very old patients). More funding to the local communities, due to the increase in responsibilities and tasks. More collaboration across sectors (horizontally) and between sectors (vertically; i.e. hospitals and the local community).

Consultation with people with dementia and carers Although no specific reference is made to people with dementia in the National Programme for Mental Health, reference is made to the ICD classification F00-F009 (organic, including symptomatic, mental disorders). The report emphasises the importance of the patients’ perspective (referred to in the report as the “user”): “Fundamental for the reform of mental health care in Norway is the emphasis placed on the users’ views and perspectives on services. The experience and knowledge possessed by users and their relatives, is unique and necessary in improving and optimising services and treatment. Participation is also vital for empowerment and for the ability to master one’s own life. This is of great value and a central vision of the National Programme for Mental Health. Users and close relatives should be involved at all levels in the decision-making process. At the system level this implies organised participation by users and relatives in planning processes, legislation, implementation of treatment programmes etc. It is of major importance that users’ perspectives are taken into consideration in decision-making throughout the services (political, administrative and professional) and at all levels (Ministry, municipalities, hospitals etc.). Accordingly, national as well as local authorities should be co-operating with users’ organisations and unions in these matters. At the individual level, the policy implies a legal right to participate in the management of necessary services.” (Norwegian Ministry of Health and Care Services, 2005, p.6) It is further stated that patients’ needs must guide the provision of services and that cooperation with patients and their families is required at all levels.

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36.1.1 References Anonymous, Security – respect – quality, Action plan for care of the elderly 1998 – 2001, Health Care Systems in Transition, HiT Summary, Norway, European Observatory on Health Care Systems, http://www.observatory.dk Information provided by Inger Jorun Edvardsen and Maija Juva Ingebretsen, R. & Eriksen, J. (2004), National Background Report for Norway, EUROFAMCARE, http://www.uke.uni-hamburg.de/extern/eurofamcare/documents/nabare_norway_rc1_a4.pdf Ministry of Health and Social Affairs website (http://odin.dep.no/hod/engelsk/publ/handlingsplaner/030005990070/dok-bn.html) Norwegian Ministry of Health and Care Services (2005), Mental Health Services in Norway, prevention – treatment – care, Helse- og Omsorgsdepartementet (http://odin.dep.no/filarkiv/233840/MentalHealthWeb.pdf) Wannag, A. (2000), Caring for the carers; a review of issues (notes from conference),http://www.phcttb.org/projects/Qualityofcare.htm- accessed on 29/4/2005

36.2 HHCP involved in older persons homecare service in Norway: roles and competences The three main personell – groups working in the home care sector are; nurses, practical nurses and assistants ( workers without training whithin health services). The nurses and to some degree the practical nurses have quite an independant professional role in the health- and care services in patients homes. ” Home” can vary from the ordinary, old hom of the patient, to special care block of flats ( with varied degree of care, from none to perosnell stationed in the block). Patients who are in great need of support from the services, but who are not yet entitled to/ in need of nursing home,often live in small flats or rooms that are co – located with a nursing home. They may receive services from the same personell as those who work in the nursing home/institution. And they more often have a closer follow – up by doctors, than patients living in their ordinary homes. In addition to the above mentioned three personell groups, physiotherapists, occupational therapists and doctors also provide home services sometimes. This, however, varies a lot from one communtity to another. It also varies as to where in the ”care – ladder” the patients live. Practical nurses are on level 4 in the EQF system , nurses are on level 6, (if they heve a masters degree they are on level 7). The assistants are placed on level 3.

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37 OLDER PERSONS HOMECARE IN ICELAND In 2015 there are almost 33.000 senior citizens in Iceland. About 11% (3.630) require admission to a nursing home. According to the literature that is expected to 10,8% of birth tunnel 67 years and older is in need of assistance. Today there are waiting list for senior citizens to get a nursing home. They need to go through the evalution and Rai have reached very ill to enter. That has changed in recent years to increase has been detached and lengthens the waiting list considerably. The Icelandic authorities are aware of aging in European countries where the birth rate has reduced impact on population trends. Life expectancy changes as the improved living conditions and better medical service and medicines. Momentum aging rapidly increased after 2000 as shown in the lower spreadsheet, especially with women. Population forecast for half the increase in the next 50 years. In general, life expectancy has increased but the service does not follow trends recovered quickly enough. There is a need for increased funds in the issue, however, the authorities try to do their best. Worth noting that recessions has been in the country since 2008 which affects the allocation of funds in health care system. If we turn our focus to the human resources of the nursing home and their education that´s how this country for Practical Nurses are a small minority of staff who work in nursing home. Unfortunately nursing home employ unskilled workers receiving the lower wages.Possibly this is done to save the labor cost and no restricions for skills. Unskilled workers are foreigners who do not speak good Icelandic and this workers have little or no knowledge of nursing the eldery. some of them are social workers who have college education (félagsliðar) or foreign unskilled labour. Only 1/3 of employees of nursing homes in Iceland are Practical nurses. 2/3 eru unskilled workers or staff who have few courses from Union Promotion (Efling) or low levels of educations. A large part of unskilled workers are foreigners who have moved to Iceland to get work and speak very poor Icelandic if any. Most come from Poland, eastern Europe and Asia. Some of the workers adapt well and learn the language and go to school and pick up health degree. But others have even a university degree from their home lands and work on other fields due to lack language. To give a realistic picture of proportion skilles as an example, figures from the human resources deparment three largest nursing home in Iceland (Grund, Eir and Hrafnista) indicate only 40 Practical nurses in 26 positisions and 99 in 57.75 care positisions. On nursing home Grund, is 33 practical nurses in 23 positisions and 134 unskill workers in 86.36 positisions. These figures show clearly that the Practical Nurses are only 25% of the staff in nursing homes. It should be noted that the staffing is understaffed and have heavy work load which increases the strain on the staff.

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Figure 28: Population pyramid of Iceland in 2007 and 2050 ( Statistics Iceland)

Figure 29: The number of eldery age group.

Background information about dementia and home care services According to the “Icelandic National Health Plan to the year 2010” published by the Ministry of Health and Social Security in 2004, “With the appropriate services and support it is fair to assume that more people would be able to stay longer at home. (…) It is important to emphasise the need to maintain and enhance physical and mental abilities, in order for senior citizens to be able to stay as long as possible in their own homes.” Methods to achieve this are outlined. These include: • •

the need to strengthen and increase cooperation and coordination of home help and the need to increase the availability of day care and health centre home services, in which the emphasis should be on round-the-clock, 7-day service and short-term hospitalisation.

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The Ministry has set itself a target, namely that by 2010 “more than 70% of citizens over the age of 80 will retain their health to the extent that they can with the appropriate support services, continue to live in their homes and participate in daily life. Legislation relating to the provision of home care services In Iceland, there are a few laws which specifically deal with issues related to the elderly. The first was enacted in 1982 and was then revised in 1989 and 1999. The underlying principle of these laws is that the elderly should be respected. The laws also state that the elderly have a legal entitlement to the services that they need and that consequently the state must ensure that their needs are met in a way that is relevant and economically feasible (Jónsson and Pálsson, 2005). The purpose of the Act on the Affairs of the Elderly, No.125 of 31 December 1999 (Act no.125 of 1999) is stated as being “to ensure that the elderly are able, for as long as possible, to enjoy a normal domestic life and that they are assured the required institutional services when needed.” An elderly person is defined as being a person aged 67 or older. This legislation, combined with the high cost of nursing home care and the desire of many elderly people to continue living in their own homes, has resulted in an increased demand for home care services (Johnson and Olafsdottir, 2005). Home care in Iceland includes health care and social services. The former is in the hands of health care centre employees pursuant to the Act on Health Care Services. The latter is handled by municipalities or the parties with which the municipalities have contracted, pursuant to the Act on Municipal Social Services. Organisation of home care services In each health care centre district there is a service council for the elderly. This service is responsible for ensuring that the elderly receive the services they need, that they are informed of the options available to them and that their needs for institutional care are assessed (Act no.125 of 1999, article 8). Home nursing services are usually provided by community health centres. Such care is organised on a regional basis. Other kinds of home care services (sometimes referred to as homemaker services) are organised by the social services sector, also on a regional basis. Financing of home care services The national health insurance finances home nursing care almost entirely. It is paid for by the state through the central government’s budget. Social services for the elderly (including home care and days care) are paid for by county councils which are funded by local governments. Nursing in the home is therefore free. Payment for other home care services is related to income. Therefore, clients may have to pay a small contribution towards the costs of such services. There are no cash benefits for home care. People attending day care centres must pay up to a maximum amount of one full basis pension (i.e. EUR 217 per month) (MISSOC, 2005). People who are in need of care can obtain a reimbursement for care costs along with their pension provided that they are on a very low pension. If eligible, the amount is calculated on the basis of each individual case in

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terms of percentages (35%, 70%, 90% or 120%) and paid to the person withdementia. In July 2001, this amounted to EUR 75, EUR 149, EUR 192 and EUR 256 respectively. Spouses my be entitled to special compensation amounting to 80% of the flat rate state pension for providing care at home if they: • • •

have suffered a loss of income as a result of stopping full-time employment; have incurred extra expenses linked to day care or paid home help; are on a low income e.g. if the spouse has no income.

Kinds of home care services available Chapter IV, article 13 of the Act no.125 of 1999 provides the following examples of geriatric services (which would also be available to elderly people with dementia). •

•

•

•

Home care services provided to the elderly residing at home. The service shall be based on case-bycase assessments of service needs and shall be geared to support for self-help. Home care services shall be provided in the evening, at night and on week-ends if necessary. An effort shall be made to organise and co-ordinate the health care and social aspects of the home care services with the welfare and needs of the elderly person in mind. Service centres for the elderly which are operated by municipalities to ensure that senior citizens are provided with company, nourishment, exercise, recreation, entertainment and health surveillance. Service centres may work independently or in connection with other services enjoyed by the elderly. Day-care centres for the elderly as a supporting measure for those who require supervision and care on a regular basis in order to continue to live at home. Day-care centres for the elderly shall provide nursing services and be fitted with facilities for exercise and medical services. Transportation services shall be provided to and from the home of the individual, as well as health assessments, exercise, recreation, social support, education, counselling and assistance in the activities of daily life. Serviced apartments for the elderly which may be privately owned, rented or residential rights apartments. Prior to the construction of serviced apartments for the elderly, construction permits must be obtained from the Minister for Health and Social Services pursuant to Article 16. Serviced apartments for the elderly shall be fitted with security systems and a choice of varied services, such as catering, laundry and cleaning and access to social activities. Payment for services provided shall be governed by the provisions of Article 20. The residents of serviced apartments shall be entitled to the same home and watch services as other residents of the municipality.

Consultation with people with dementia and carers The “Icelandic National Health Plan to the year 2010” mentions the objective of ensuring that every health care institution establishes a formal quality development procedure and follows its own plan with regard to quality issues and that over 90% of patients should be satisfied with the health care services they receive. It is not clear to what extent this would apply to the provision of home care services for people with dementia.

37.1.1 References Act on the Affairs of the Elderly, No.125, 31 December 1999 (with amendments up to Act No.38/2004),http://eng.heilbrigdisraduneyti.is/media/Laws%20in%20english/Act_on_the_Affairs_of_the_Elde rly.pdf#search='Act%20on%20the%20Affairs%20of%20the%20Elderly%20AND%20Iceland' 562634-EPP-1-2015-IT-EPPKA2-SSA

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Alzheimer Europe (2001), Equality in the Provision of Care at Home, Alzheimer Europe Health information Unit of WHO Regional office for Europe, Highlights on Health in Iceland,http://www.who.dk/document/E72496.pdf Johnson, P. and Oafsdottir, T. (2005), WHHO-Compendium Text (extract on Iceland),http://www.nahc.org/WHHO/WHHOcomptext.html Jónsson, P. V. and Pálsson, H. (2005), Toward informed and evidence-based elderly care: the RAI experience in Iceland, http://www.milbank.org/reports/interRAI/Iceland.html MISSOC (2005), Comparative tables: Iceland,http://www.europa.eu.int/comm/employment_social/missoc/2002/is_part12_en.htm The Ministry of Health and Social Security (2004), The Icelandic National Health Plan to the year 1020, abridged version, http://www.heilbrigdisraduneyti.is/media/Skyrslur/heilbenska5mai.pdf#search='Icelandic%20National%20Hea lth%20Plan'

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38 Annex 1: Questionnaire targeting HHCPs

ERASMUS PLUS 2015 SECTOR SKILLS ALLIANCES AGREEMENT No. 2015 – 3212 / 001 – 001 PROJECT No. 562634-EPP-1-2015-IT-EPPKA2-SSA

WP2 – PRIMARY DATA GATHERING QUESTIONNAIRE TARGETING HHCPs Annex to D2.1

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PREMISES The questionnaire should be implemented through an online tool that should be defined by the consortium. The online tool should allow for the management of “customized” items thanks to the possibility of using “conditioned items”, i.e. items that appear/not appear on the base of the answer given to a previous item. As defined by the Consortium, the questionnaire will be characterized by: -

a “core” of items that should be included in Italian, Spanish and Finnish questionnaire (IN BLACK); optional items which can be included in the questionnaire (as optional) or not (IN RED) specific context-related answer options, which could be included only in some countries; in order to provide examples, this draft includes possible answer option for Italian context in purple text, for Finland in green and for Spain in blue.

INTRODUCTIVE TEXT FOR THE USER “Dear professional, Thank you in advance for helping us in collecting data about homecare service in Italy. Your collaboration is very precious in order to support the CARESS European Project trying to improve the service both at International and local level. What we’re asking to you is to answer to few questions concerning your activity as a professional in the field of older adults homecare. Please, answer describing the ACTUAL activity you carry out while acting as a PROFESSIONAL in OLDER ADULTS HOMECARE. The questionnaire is anonymous and no professional evaluation will be carried out on the collected data. You can fill-in the questionnaire in more-times, by saving the answers already provided. Thank you again for your collaboration ”

SECTION 0: WHAT PROFESSIONAL ARE YOU? 0.1 Have you carried out an older adult homecare activity in the LAST 5 YEARS? 1 Yes [continue the questionnaire] 2 No [stop here] 2.1 Which is your profession? [Please select only one of the following options] 1. Nurse 2. Physiotherapist Erasmus Plus – SSA 2015

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3. Psychologist 4. Educator 5. Home care assistant/ home helper 6. Other [specify_______________________________________] 7. Practical Nurse 8. Occupational Therapist 9. Dietitian 10. Speech therapist 11. OSS – Social Health Operator 12. Social Guardian 2.2 Which of the following contexts represent your activity as practitioner in homecare? 1. Public institutional homecare provider 2. Private homecare provider 3. Freelance professional activity 4. Other [specify_______________________________________]

2.3 Please specify your birth year [____________________________________]

SECTION 1 – YOUR ACTUAL ACTIVITY AS A PROFESSIONAL In this section of the questionnaire we will focus on your ACTUAL activity as a professional in homecare, what really happens when you provide your service at the older person’s own home. You should list the activities you normally carry out, the needs you address and the competencies required by these activities and needs.

1.1 Which of the following activities do you normally carry out at the older person’s home? [Please select all of the activities you normally carry out - more than one choice is possible] CLINICAL ACTIVITIES RELATED TO ASSESSMENT AND PLANNING 1. 2. 3. 4.

evaluation of customer needs evaluation of health condition in-home health exams (e.g. taking blood sample) personal assistance planning

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5. 6. 7. 8. 9.

companionship support and assistance in social relationships Home Environment assessment intervention for a proper prescription and use of principals devices in home environment education in health management and lifestyle

SUPPORT TO INDEPENDENCE 10. personal hygiene (bathing, grooming, etc.) 11. house management and cooking 12. Support to daily activities (shopping, going to a medical appointment, etc.) CLINICAL ACTIVITY RELATED TO THERAPY 13. prevention interventions 14. monitoring healthy lifestyle 15. pharmacological treatment and homeostasis maintenance, performance relating to excretory functions and skin treatment 16. rehabilitation activities (walking, exercises, etc.) 17. positioning and supporting mobility CAREGIVER 18. educational interventions for caregivers TEAM/REPORT 19. team meeting and contacts with the other professionals involved in older person’s assistance 20. report of the activities conducted 21. Other [specify_______________________________________] 1.2 What is the average time ACTUALLY spent at the older person’s home in your daily activity? 1. 2. 3. 4. 5. 6. 7.

Up to 15 minutes From 15 to 30 minutes From 30 min to 1 hour From 1 to 2 hours From 2 to 4 hours From 4 to 8 hours Other [specify_______________________________________]

1.3 How many times on average do you visit the same older person’s in a week? 1. Once Erasmus Plus – SSA 2015

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2. 3. 4. 5.

From 2 to 3 times From 3 to 5 times From 5 to 7 times More than 7 times

1.4 Let’s focus on the needs of the older person. Which of the following possible needs to do you normally address in your daily activity? [Please select all of the needs you normally address - more than one choice is possible] Need for BASIC PERSONAL attention

1. 2. 3. 4.

Need to be supported in hygiene including shower or bath or oral hygiene Need of assistance for dressing up and undressing Need of assistance for transfers and mobilization at home Need for a proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home 5. Prevention of skin lesions through proper hygiene, postural changes and specific skin care. 6. Specific care of urinary and fecal incontinence. 7. Need of support and assistance in food management including preparation meals and purchase of foods 8. Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). 9. Need of support and assistance to accomplish administrative procedures including those relating with health. 10. Need of support for the management of technological devices for home health monitoring 11. Need of support in mobility out of home Need for BIO-PSYCHO PHYSICAL HEALTH support.

12.Need of protection and promotion of the psychological and emotional welfare and protection 13. Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. 14. Need to be supported in the self-management of his/her physical health. 15. Need to be supported in the self-management of his/her mental health Other needs in situations involving particularly PREVALENT DISEASES in aging.

16. Need to be supported and educated in proper positioning and postural changes to prevent physical disorders 17. Need to feel safe and secure in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). Erasmus Plus – SSA 2015

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18. Need of support and rehabilitation in toilet habits. 19. Need of Support in adherence to treatment including preparing medication, reviewing medication consumpion. 20. Need of support in compliance with non pharmachological treatment including active and health lifestyle such as prescribed diet, food intake control, physical excercises 21. Need of support or interventions in managing meals in case of eating disorder or malnutrition 22. Need of support and assistance for effective communication. 23. Need of support and rehabilitation of cognitive abilities (memory, attention, orientation etc.) 24. Need of support and management of behavior disorders associated with dementia. 25. Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

The need of a COMPREHENSIVE CONSIDERATION of the person

26. Need to be self-determined and independent. 27. Need to a respectful treatment according to his/her dignity 28. Need for protection of user privacy and intimacy 29. Need to see defended and to be supported in his own interests 30. Need to feel a deep respect regarding values (including religious beliefs and spiritual needs). 31. Need to be informed about your state of health and the available treatment and care options

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1.5 Let’s focus on the PROFESSIONAL COMPETENCIES required by homecare. What do you think are the COMPETENCIES required to perform the activities you ACTUALLY carry out and to address the needs you ACTUALLY target? How do you master these competencies? How did you acquire these competences? Please select “required” in the list below for all of the competencies that you think are required. Then, for each of the “required” competencies specify: -

The level you self-esteem you master the competence If you acquired the competence attending a school, a training course or an academic course If you acquired the competence by working practice

COMPETENCE

IS THE COMPETENCE REQUIRED?

Basic knowledge in medical MENU DROPDOWN assistance NOT REQUIRED/REQUIRED [DEFAULT NOT REQUIRED]

SELF-EVALUATE THE LEVEL YOU MASTER THE COMPETENCE MENU DROPDOWN [NO ANSWER Low Mastery Average Mastery High Mastery] [DEFAULT NO ANSWER]

COMPETENCE ACQUIRED ATTENDING A SCHOOL, A TRAINING COURSE OR AN ACADEMIC COURSE MENU DROPDOWN NO/YES/NO ANSWER [DEFAULT NO ANSWER]

COMPETENCE ACQUIRED BY WORKING PRACTICE

MENU DROPDOWN NO/YES/NO ANSWER [DEFAULT NO ANSWER]

Basic medical knowledge specifically related to my profession Basics in anatomy and pathology Erasmus Plus – SSA 2015

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Environmental and personal hygiene basic concepts Basics in home economics Basics in dietetic Basics in older person’s healthy lifestyles Basic psychology elements Basics in domestic safety and prevention Basics in social-health services organizations and networks Knowledge about the main aids and devices for older and disabled people Basic on the main characteristics of peoples with different levels of autonomy Basics in law and human rights frameworks Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Other specific basic medical procedures related to my profession Procedures for providing medical therapies Procedures for providing physical therapies Erasmus Plus – SSA 2015

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Procedures for environmental hygiene Procedures for personal hygiene Procedures for customer moving Cooking Procedures for defining an eating plan Procedures for monitoring healthy lifestyles Managing errands Usage of reporting and monitoring tools Procedures for fostering customers going out of home Fostering customers social and familiar relations Using ICT for social participation Using ICT for health status monitoring Providing the customer with contextualized and personalized information about the network of services he/she can rely on Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Competences for caring with Erasmus Plus – SSA 2015

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dignity Competences for managing conflicts Competences for collaborating with other practitioners Competences for coordinating the work of other practitioners Competences for working in a group /equip /staff Competences for evaluating customer needs and adapting the service Competences for evaluating customer mental health status Competences for empowering the customer Grief support Competencies for terminal illness support Competencies for supporting the customer in building up an independent living path

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1.6.a. Are there other competencies that you think are required to perform the activities you actually carry out and to address the needs you actually target in addition to those listed below? 1. Yes 2. No 1.6.b. If yes, please list them below: [conditioned item: if 1.6.a = yes] 1)______________________________ 2)_______________________________ 3)_________________________________ 4)________________________________ 5)__________________________________

SECTION 2 –TARGETED NEEDS AND COMPETENCES IN AN IDEAL HOMECARE In this section of the questionnaire we will focus on an IDEAL situation, asking you to identify possible further older persons’ needs to address and possible further competencies necessary to target them. 2.1.a. Do you think that there are some users’ needs that should be addressed by your activity AS SPECIFIC PROFESSIONAL in addition to those selected above? 1. Yes 2. No 2.1.b If yes, which one of the following? [Please select all of the needs you currently don’t address but you think you should address - more than one choice is possible] [conditioned item: if 2.1.a = yes] Need for BASIC PERSONAL attention

1. 2. 3. 4.

Need to be supported in hygiene including shower or bath or oral hygiene Need of assistance for dressing up and undressing Need of assistance for transfers and mobilization at home Need for a proper maintenance of the house including cleaning and order washing, ironing and organization of the clothes inside the home 5. Prevention of skin lesions through proper hygiene, postural changes and specific skin care. 6. Specific care of urinary and fecal incontinence. Erasmus Plus – SSA 2015

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7. Need of support and assistance in food management including preparation meals and purchase of foods 8. Need of basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). 9. Need of support and assistance to accomplish administrative procedures including those relating with health. 10. Need of support for the management of technological devices for home health monitoring 11. Need of support in mobility out of home Need for BIO-PSYCHO PHYSICAL HEALTH support.

12.Need of protection and promotion of the psychological and emotional welfare and protection 13. Need of assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. 14. Need to be supported in the self-management of his/her physical health. 15. Need to be supported in the self-management of his/her mental health Other needs in situations involving particularly PREVALENT DISEASES in aging.

16. Need to be supported and educated in proper positioning and postural changes to prevent physical disorders 17. Need to feel safe and secure in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). 18. Need of support and rehabilitation in toilet habits. 19. Need of Support in adherence to treatment including preparing medication, reviewing medication consumpion. 20. Need of support in compliance with non pharmachological treatment including active and health lifestyle such as prescribed diet, food intake control, physical excercises 21. Need of support or interventions in managing meals in case of eating disorder or malnutrition 22. Need of support and assistance for effective communication. 23. Need of support and rehabilitation of cognitive abilities (memory, attention, orientation etc.) 24. Need of support and management of behavior disorders associated with dementia. 25. Need of technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc ...

The need of a COMPREHENSIVE CONSIDERATION of the person

26. Need to be self-determined and independent. Erasmus Plus – SSA 2015

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27. Need to a respectful treatment according to his/her dignity 28. Need for protection of user privacy and intimacy 29. Need to see defended and to be supported in his own interests 30. Need to feel a deep respect regarding values (including religious beliefs and spiritual needs). 31. Need to be informed about your state of health and the available treatment and care options

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2.2 Which of the following competencies do you think are REQUIRED for addressing the ADDITIONAL NEEDS selected above? How do you master these competencies? How did you acquire these competences? [conditioned item: if 2.1.a = yes] Please select “required” in the list below for all of the competencies that you think are required for the additional needs Then, for each of the “required” competencies specify: -

The level you self-esteem you master the competence If you acquired the competence attending a school, a training course or an academic course If you acquired the competence by working practice

COMPETENCE

IS THE COMPETENCE REQUIRED?

Basic knowledge in medical MENU DROPDOWN assistance NOT REQUIRED/REQUIRED [DEFAULT NOT REQUIRED]

SELF-EVALUATE THE LEVEL YOU MASTER THE COMPETENCE MENU DROPDOWN [NO ANSWER Low Mastery Average Mastery High Mastery] [DEFAULT NO ANSWER]

COMPETENCE ACQUIRED ATTENDING A SCHOOL, A TRAINING COURSE OR AN ACADEMIC COURSE MENU DROPDOWN NO/YES/NO ANSWER [DEFAULT NO ANSWER]

COMPETENCE ACQUIRED BY WORKING PRACTICE

MENU DROPDOWN NO/YES/NO ANSWER [DEFAULT NO ANSWER]

Basic medical knowledge specifically related to my profession Basics in anatomy and pathology Environmental and personal hygiene basic concepts Basics in home economics Erasmus Plus – SSA 2015

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Basics in dietetic Basics in older person’s healthy lifestyles Basic psychology elements Basics in domestic safety and prevention Basics in social-health services organizations and networks Knowledge about the main aids and devices for older and disabled people Basic on the main characteristics of peoples with different levels of autonomy Basics in law and human rights frameworks Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Other specific basic medical procedures related to my profession Procedures for providing medical therapies Procedures for providing physical therapies Procedures for environmental hygiene Procedures for personal Erasmus Plus – SSA 2015

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hygiene Procedures for customer moving Cooking Procedures for defining an eating plan Procedures for monitoring healthy lifestyles Managing errands Usage of reporting and monitoring tools Procedures for fostering customers going out of home Fostering customers social and familiar relations Using ICT for social participation Using ICT for health status monitoring Providing the customer with contextualized and personalized information about the network of services he/she can rely on Basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) Competences for caring with dignity Competences for managing conflicts Erasmus Plus – SSA 2015

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Competences for collaborating with other practitioners Competences for coordinating the work of other practitioners Competences for working in a group /equip /staff Competences for evaluating customer needs and adapting the service Competences for evaluating customer mental health status Competences for empowering the customer Grief support Competencies for terminal illness support Competencies for supporting the customer in building up an independent living path 2.3.a. Are there other competencies that you think are required to address the additional needs? 1. Yes 2. No 2.3.b. If yes, please list them below: [conditioned item: if 2.3.a = yes] 1)______________________________ 2)_______________________________ Erasmus Plus – SSA 2015

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Deliverable 2.1

3)_________________________________ 4)________________________________ 5)__________________________________

SECTION 3 – YOUR OPINION ABOUT YOUR RELATIONSHIP WITH THE USER Please specify you opinion about each of the following sentences choosing a number in a scale from 1=”I totally disagree” to 5=”I totally agree” 3.1 I feel I can help the customer to keep social and family relationships. Totally disagree 1

Disagree

Uncertain

Agree

Totally agreee

2

3

4

5

3.2 I feel I have the capacity to help the customer to solve his /her daily problems or to know where to find support Totally disagree 1

Disagree

Uncertain

Agree

Totally agreee

2

3

4

5

3.3 I feel my work respects the customer´s lifestyle and habits Totally disagree 1

Disagree

Uncertain

Agree

Totally agreee

2

3

4

5

3.4I am aware/I’ve been properly informed about f his/her mental health status, beside to the general health status Totally disagree 1

Disagree

Uncertain

Agree

Totally agreee

2

3

4

5

3.5 I feel I have the capacity to pay attention to the customer´s problems and comments Totally disagree 1

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Disagree

Uncertain

Agree

Totally agreee

2

3

4

5

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SECTION 4 – EVALUATION OF OLDER PERSONS’ NEEDS 4.1.a Do you normally participate in the definition of the older person’s needs? [conditioned item: if 0.2 = 1 or 2 (no freelance)] 1. Yes 2. No 4.2.a Do you normally participate in the definition of a personalized homecare plan? [conditioned item: if 0.2 = 1 or 2 (no freelance)] 1. Yes 2. No 4.1.b Do you formalize in a sheet, a chart or a report the initial evaluation of older person’s needs? [conditioned item: if 0.2 = 3 or 4 (freelance or other)] 1. Yes 2. No 4.2.b Do you formalize in a sheet, a chart or a report a personalized homecare plan for the older person? [conditioned item: if 0.2 = 3 or 4 (freelance or other)] 1. Yes 2. No 4.3 Do you normally evaluate in itinere elderly needs in order to possibly refine the homecare plan according to changing situations? 1. Yes 2. No 4.4.a Do you think do you have the proper competencies to evaluate older person’s needs and build a personalized homecare plan ?: [conditioned item: if 4.1.a or 4.1.b = yes] 1. Yes 2. No 4.4.b. If no, please list the competencies you feel you lack?: [conditioned item: if 4.4.a = no] Erasmus Plus – SSA 2015

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1)______________________________ 2)_______________________________ 3)_________________________________ 4)________________________________ 5)__________________________________ 4.5. While defining a homecare plan, do you set your intervention in a more general personalized path for independent life and dignity? 1. Yes 2. No 4.6.a. Do you think do you have the proper competencies to set your intervention in a more general personalized path for independent life and dignity? [conditioned item: if 4.5.a = yes] 1. Yes 2. No 4.6.b. If no, please list the competencies you feed you lack?: [conditioned item: if 4.6.a = no] 1)______________________________ 2)_______________________________ 3)_________________________________ 4)________________________________ 5)__________________________________

SECTION 5 - ROLE OF THE HOMECARE PROVIDER ORGANIZATION IN THE DELIVERY OF THE SERVICE [conditioned section: if 0.2 = 1 or 2 (no freelance)] 5.1.a Does your organization provide you with detailed operative guidelines? 1. Yes 2. No 5.1.b If yes, what is the level of your autonomy with respect to the guidelines? Please select a value from 1=no autonomy to 5=complete autonomy Erasmus Plus – SSA 2015

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1

2

3

4

5

5.2 In which way do you report to your organization the activities daily carried out? 1. 2. 3. 4. 5. 6. 7.

I provide no report Only by speech By weekly reports on a predefined format By daily reports on a predefined format By weekly written reports without predefined format By daily written reports without predefined format Other [specify________________________]

SECTION 6 – YOUR EDUCATIONAL and CAREER PATHWAY 6.1 Which is your educational qualification? [close set of answers to be defined specifically for each country] 1. 6.2.a Do you have additional professional qualifications? 1. Yes 2. No 6.2.b. If yes, please specify [conditioned item: if 6.2.a = yes] 1)______________________________ 2)_______________________________ 3)_________________________________ 6.3 Since how many years have you been working in older persons’ homecare? 1. 2. 3. 4. 5.

Less than 1 year From 1 to 5 years From 5 to 10 years From 10 to 20 years More than 20 years

6.4 How many career advancements have you experienced working in homecare? [conditioned section: if 0.2 = 1 or 2 (no freelance)] 1. None 2. One 3. Two Erasmus Plus – SSA 2015

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4. Three 5. More than three 6.5 Do the career advancements happened in the same provider organization or changing employer? [conditioned item: if 6.4≠none] 1. same organization 2. changing employer 3. both

SECTION 7 – ATTITUDE TOWARD LONGLIFE LEARNING 7.1. How many longlife learning courses did your provider organization propose to you in the last 5 years? [conditioned section: if 0.2 = 1 or 2 (no freelance)] 1. 2. 3. 4. 5. 6. 7.

None One Two Three Four Five More than five

7.2 How many longlife learning courses did you attend in the last 5 years? 1. 2. 3. 4. 5. 6. 7.

None One Two Three Four Five More than five

7.3 Do you think that longlife learning is important for your profession? Please specify the level of importance in a scale from 1=no importance to 5=extreme importance 1

Erasmus Plus – SSA 2015

2

3

4

5

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39 Annex 2: Structured interview to older adults

ERASMUS PLUS 2015 SECTOR SKILLS ALLIANCES AGREEMENT No. 2015 – 3212 / 001 – 001 PROJECT No. 562634-EPP-1-2015-IT-EPPKA2-SSA

WP2 - Older Adults Interview Supporting Tool PIN participant

Interviewer

Interviewer signature

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1

Interview Date

2

Birth Date

3

Caregiver present

4

Education Level

5

Gender

6

Method of the interview

Yes

□

□ primary Male □

Location of user living

N/A

□ secondary secondary (first (first degree) degree)

□

□Bachelor degree

□ Master degree

□

Female -other (what?) …………………………………………..

-by phone

7

□ □

No

City

□

center

□

-personally

□

City periphery

Big

□

village

…………………………………….…… Small

□

village

Country/mountain

□ □

SECTION 0 Dear MS/Mr…. Let’s start with few information about the homecare service that you experienced. Please refer to only one service/experience. 0.1 Which kind of professional/professionals provided you with the service? Don’t list possible answers to the user. Select one or more options according to user free speech

0.□ 1.□ 2.□ 3.□ 4.□ 5.□ 6.□ 7.□ 8.□ 9.□ 10.□ 11.□ 12.□

Nurse Physiotherapist Psychologist Educator Home care assistant/ home helper Other [specify_______________________________________] Practical Nurse [only for Finland] Occupational Therapist [only for Italy] Dietitian [only for Italy] Speech therapist [only for Italy] OSS – Social Health Operator [only for Italy] Social Guardian [only for Italy] Assistente Domiciliare tutelare [only for Italy]

NOTES:

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SECTION 1 1.1 Now I will read a list of activities. For each one you should say to me if this activity has been

carried out or not. 1.□ 2.□ 3.□ 4.□ 5.□ 6.□ 7.□ 8.□ 9.□ 10.□ 11.□ 12.□ 13.□ 14.□ 15.□ 16.□ 17.□ 18.□

evaluation of your needs evaluation of your health condition in-home health exams (e.g. taking blood sample) personal assistance planning companionship support and assistance in social relationships Home Environment assessment in terms of safety, hygiene, etc. Assistance in the prescription and use of principals tools you use in home environment (crutches, wheelchair, blood pressure measurement machine, etc.) education in health management and lifestyle personal hygiene (bathing, grooming, etc.) house management and cooking Support to daily activities (shopping, going to a medical appointment, etc.) Illness prevention interventions monitoring healthy lifestyle pharmacological treatment and skin treatment rehabilitation activities (walking, exercises, etc.) positioning and supporting mobility educational interventions for your relatives and friends

1.2 Do you want to point out other activities that the professional carried out at your own home during the service? 1.□ 2.□

Yes No

1.3 Which ones? Take note according to user free speech

1) _____________________________________________________________________ 2) _____________________________________________________________________ 3) _____________________________________________________________________ 4) _____________________________________________________________________ 5) _____________________________________________________________________

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Let’s focus on the time spent by the practitioner at your home. 1.4 What is the average time ACTUALLY spent by professional at your home each time he/she comes?

Read the question without listing the possible options. You have to check the proper option on the base of the free speech of the user

1.□ 2.□ 3.□ 4.□ 5.□ 6.□ 7.□

Up to 15 minutes From 15 to 30 minutes From 30 min to 1 hour From 1 to 2 hours From 2 to 4 hours From 4 to 8 hours Other [specify_______________________________________]

1.5 How many times on average do you receive the visit of the professional at your home in a week? Read the question without listing the possible options. You have to check the proper option on the base of the free speech of the user

1.□ 2.□ 3.□ 4.□ 5.□ 6.□

Less than once Once From 2 to 3 times From 3 to 5 times From 5 to 7 times More than 7 times

1.6 How can you define the relation/interaction that you normally establish with the professional

that visit you at home? I’ll give you some options and you can choose more than one of them 1.□ 2.□ 3.□ 4.□ 5.□

deep friendly professional detached Other [specify____________________________________________________]

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SECTION 2 In this section you should identify the user needs that are fulfilled by the service and needs that are not fulfilled but they’d like to be fulfilled. Using the same matrix of data (the one in the following page), you have to classify answers to 3 main questions, in 3 different columns in the matrix, identified by the number of the question. As to the first question (2.1), you have to check in column 2.1 the needs you deem that are mentioned by the user in a free speech. As to the second question (2.2), you have to try to identify further fulfilled needs by suggesting macro-categories of needs. If the user decide to add some needs to the ones listed in 2.1 you have to check them in column 2.2. As to the third question (2.3), you have to check in column 2.3 the needs you deem that are mentioned by the user in a free speech.

Let’s focus on your needs. 2.1 Can you tell me some needs of your own that the professional fulfilled providing the service? 2.2 Let’s see if discussing together we’ll be able to identify further needs that have been fulfilled. What about -

Needs of support in daily activities (including hygiene, mobility, dressing, cleaning, food, mobility in and out of home etc.) and managing home and own interests

Some of these needs have been fulfilled? -

technical help in managing medical tools or help with the assumption and management of therapy; needs of support to maintain an healthy lifestyle and wellbeing needs for privacy, intimacy, independency and protection from mistreatments.

Some of these needs have been fulfilled? 2.3 Let’s finally focus on needs that you’d like to have satisfied but the professional doesn’t fulfilled. Can you mention some of them? IF YOU ARE NOT ABLE TO CLASSIFY IMMEDIATELY THE ANSWER, USE THE SPACE BELOW TO TAKE NOTES

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NEEDS MACRO CATEGORIES

Need of support in daily activities (including hygiene, mobility, dressing, cleaning, food, mobility in and out of home etc.) and managing home and own interests

2.1

2.2

2.3

LIST OF NEEDS support in hygiene including shower, bath or oral hygiene assistance for dressing up and undressing help in toilet such as transferring to the toilet, cleaning self or uses bedpan or commode assistance for transfers and mobilization at home for example from bed to chair or from chair to stand up help in managing incontinence of bowel or bladder support and assistance in feeding including preparation meals and gets food from plate in to mouth support on shopping and purchases such as select the products (food or newspapers), giving the right amount of money and managing the rest maintenance of the house including cleaning the floors, laundry, organization of the clothes inside the home etc. support in mobility out of home including the use of public or private transportations basic maintenance of household appliances and the ones of personal use, including protection and security review tasks of housing (ventilation, gas, electricity ...). support and assistance to accomplish administrative procedures including to handle finances prevention of skin lesions through proper hygiene and specific skin care.

Support in particular health conditions that require specialists such as skin lesions, technical help in managing medical tools, assumption and management of therapy. Need for support in prevention from any health risk (including home suitability) and maintenance of healthy lifestyle and wellbeing including physical health (such as physical exercises or walks) mental wellbeing, and social relationships. The need of a comprehensive and respectful consideration of myself, according to my dignity and values including privacy, intimacy, independency and protection from mistreatments.

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support in proper positioning and postural changes to prevent physical and skin disorders support or interventions in feeding due to in case of eating disorder and dysphagia support and assistance for effective communication Support in adherence to treatment including preparing medication, reviewing medication consumption support and help in memory difficulties (reminding things to do), names, locations orientation when you are out of home technical support with external devices: Oxygen, NIMV (non-invasive mechanical ventilation), feed pumps, infusion pumps, home peritoneal dialysis, etc support in compliance with not pharmacological treatment including active and health lifestyle such as prescribed diet, food intake control, physical exercises safety and security in his/her surroundings including suitability of the home to prevent "static causes "of falls (assistance in removing barriers and adaptation of the home). protection and promotion of the psychological and emotional welfare assistance to avoid situations of loneliness and isolation and facilitate family and social relations or participation. need to be self-determined and independent need to a respectful treatment according to his/her dignity need for protection of user privacy and intimacy need to see defended and to be supported in his own interests need to feel a deep respect regarding values (including religious beliefs and spiritual needs) need to be informed about your state of health and the available treatment and care options

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2.4 Ok. Now I try to summarize and list both the needs you feel fulfilled and the needs that are not fulfilled but you’d like them to be. Read the answers you checked in the matrix above, trying to use a user-friendly language.

Can you say which needs (independently if they are fulfilled or not) have an high importance and priority for you? For example, can you tell me 3 of them in order of importance, from the most important to the less important one? 1- ______________________________________________________________________________________ 2.- ______________________________________________________________________________________ 3.- ____________________________________________________________________________________ POSSIBLE NOTES:

SECTION 3 3.1 Now please mention THREE abilities or characteristics that you consider should be fundamental for a homecare professional to have. 1- ______________________________________________________________________________________ 2.- ______________________________________________________________________________________ 3.- ____________________________________________________________________________________ POSSIBLE NOTES:

3.2 Now please mention THREE aspects you consider have improved your quality of life since the homecare professional assists you. 1- ______________________________________________________________________________________ 2.- ______________________________________________________________________________________ 3.- ____________________________________________________________________________________ POSSIBLE NOTES:

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40 Annex 3: Finnish questionnaire targeting HHCPs: detailed percentages of knowledges, skills and competences (KSC) General competence in medical knowledge specifically related to the profession 1. KSC don’t needed 0,2 % 2. KSC needed 85,5 % 3. Satisfactory level of KSC 3,3 % 4. Good level of KSC 58,9 % 5. Excellent level of KSC 34,3 % 1. KSC developed during education 59,3 % 2. KSC developed worked based 60,5 % General knowledge, skills and competences in anatomy, physiology and patology 6. KSC don’t needed 4,0 % 7. KSC needed 80,6 % 8. Satisfactory level of KSC 16,1 % 9. Good level of KSC 61,4 % 10. Excellent level of KSC 17,3 % 3. KSC developed during education 79,9 % 4. KSC developed worked based 37,1 % General knowledge, skills and competences in personal and environmental hygiene 1. KSC don’t needed 3,5 % 2. KSC needed 82,1 % 3. Satisfactory level of KSC 0,2 % 4. Good level of KSC 32,6 % 5. Excellent level of KSC 61,2 % 1. KSC developed during education 53,5 % 2. KSC deleloped worked based 65,6 % General knowledge, skills and competence in home economics 1. KSC don’t needed 19,2 % 2. KSC needed 65,8 % 3. Satisfactory level of KSC 5,2 % 4. Good level of KSC 36,5 % 5. Excellent level of KSC 48,5 % 1. KSC developed during education 34,4 % 2. KSC deleloped worked based 71,7 % General knowledge, skills and competences in nutrition/ dietetic 1. KSC don’t needed 6,1 % 2. KSC needed 78,6 % 3. Satisfactory level of KSC 3,7 % 562634-EPP-1-2015-IT-EPPKA2-SSA

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4. Good level of KSC 51,5 % 5. Excellent level of KSC 39,6 % 1. KSC developed during education 72,5 % 2. KSC deleloped worked based 45,9 %

General knowledge, skills and competences in healthy lifestyle of older people 1. KSC don’t needed 10,3 % 2. KSC needed 75,5 % 3. Satisfactory level of KSC 2,8 % 4. Good level of KSC 51,6 % 5. Excellent level of KSC 39,3 % 1. KSC developed during education 63,3 % 2. KSC deleloped worked based 52,8 % General knowledge, skills and competences in psychology elements 6. KSC don’t needed 23,3 % 7. KSC needed 60,8 % 8. Satisfactory level of KSC 22,4 % 9. Good level of KSC 50,1 % 10. Excellent level of KSC 16,8 % 3. KSC developed during education 70,2 % 4. KSC deleloped worked based 39,2 % General knowledge, skills and competences in safety at home and prevention of accidents 1. KSC don’t needed 9,1 % 2. KSC needed 57,0 % 3. Satisfactory level of KSC 5,6 % 4. Good level of KSC 57,0 % 5. Excellent level of KSC 30,7 % 1. KSC developed during education 48,1 % 2. KSC deleloped worked based 66,5 % General knowledge, skills and competences in social-health services organizations and networks 1. KSC don’t needed 10,8 % 2. KSC needed 73,5 % 3. Satisfactory level of KSC 30,0 % 4. Good level of KSC 52,9 % 5. Excellent level of KSC 10,5 % 1. KSC developed during education 36,8 % 2. KSC deleloped worked based 72,4 %

General knowledge, skills and competences about the main aids and devices for older and disabled people 1. KSC don’t needed 7,0 % 2. KSC needed 78,3 % 3. Satisfactory level of KSC 8,9 % 4. Good level of KSC 56,5 % 5. Excellent level of KSC 27,8 % 1. KSC developed during education 29,7 % 2. KSC deleloped worked based 79,9 %

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General knowledge, skills and competences in basic on the main characteristics of peoples with different levels of autonomy 1. KSC don’t needed 40,9 % 2. KSC needed 44,7 % 3. Satisfactory level of KSC 24 % 4. Good level of KSC 50,6 % 5. Excellent level of KSC 8,8 % 1. KSC developed during education 28,5 % 2. KSC deleloped worked based 58,9 % General knowledge, skills and competences in basics in law and human rights frameworks 1. KSC don’t needed 13,8 % 2. KSC needed 71,4 % 3. Satisfactory level of KSC 27,6 % 4. Good level of KSC 52,2 % 5. Excellent level of KSC 11,5 % 1. KSC developed during education 70,5 % 2. KSC deleloped worked based 35,1 % General knowledge, skills and competences in basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) 1. KSC don’t needed 0,5 % 2. KSC needed 84,4 % 3. Satisfactory level of KSC 3,3 % 4. Good level of KSC 42,0 % 5. Excellent level of KSC 49,0 % 1. KSC developed during education 75,1 % 2. KSC deleloped worked based 54,3 % General knowledge, skills and competences in other specific basic medical procedures related to my profession 1. KSC don’t needed 5,9 % 2. KSC needed 78,3 % 3. Satisfactory level of KSC 9,2 % 4. Good level of KSC 57,5 % 5. Excellent level of KSC 25,5 % 1. KSC developed during education 51,7 % 2. KSC deleloped worked based 69,8 % Knowledge, skills and competences in procedures for providing medical therapies 1. KSC don’t needed 0,2 % 2. KSC needed 84,6 % 3. Satisfactory level of KSC 3,0 % 4. Good level of KSC 39,9 % 5. Excellent level of KSC 53,1 % 1. KSC developed during education 74,6 % 2. KSC deleloped worked based 54,3 % Knowledge, skills and competences in procedures for providing physical therapies 1. KSC don’t needed 45,8 % 2. KSC needed 41,1 % 562634-EPP-1-2015-IT-EPPKA2-SSA

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3. Satisfactory level of KSC 29,2 % 4. Good level of KSC 44,4 % 5. Excellent level of KSC 6,5 % 1. KSC developed during education 41,4 % 2. KSC deleloped worked based 53,0 % Knowledge, skills and competences in procedures for environmental hygiene 1. KSC don’t needed 27,9 % 2. KSC needed 57,3 % 3. Satisfactory level of KSC 10,1 % 4. Good level of KSC 58,0 % 5. Excellent level of KSC 19,2 % 1. KSC developed during education 40,6 % 2. KSC deleloped worked based 58,0 % Knowledge, skills and competences in procedures for personal hygiene 1. KSC don’t needed 6,3 % 2. KSC needed 78,5 % 3. Satisfactory level of KSC 0,5 % 4. Good level of KSC 28,8 % 5. Excellent level of KSC 65,6 % 1. KSC developed during education 55,5 % 2. KSC deleloped worked based 59,0 %

Knowledge, skills and competences for procedures for customer moving 1. KSC don’t needed 7,2 % 2. KSC needed 78,6 % 3. Satisfactory level of KSC 2,1 % 4. Good level of KSC 53,4 % 5. Excellent level of KSC 39,2 % 1. KSC developed during education 48,3 % 2. KSC deleloped worked based 69,7 % General knowledge, skills and competences in cooking 1. KSC don’t needed 48,4 % 2. KSC needed 39,0 € 3. Satisfactory level of KSC 4,2 % 4. Good level of KSC 35,7 % 5. Excellent level of KSC 41,1 % 1. KSC developed during education 32,9 % 2. KSC deleloped worked based 55,8 % 40.1.1 General knowledge, skills and competences for procedures for defining an eating plan (nutrition) 1. KSC don’t needed 26,3 % 2. KSC needed 60,1 % 3. Satisfactory level of KSC 8,9 % 4. Good level of KSC 49,9 % 5. Excellent level of KSC 29,8 % 1. KSC developed during education 52,9 % 562634-EPP-1-2015-IT-EPPKA2-SSA

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2. KSC developed worked based 50,6 % 40.1.2 General knowledge, skills and competences for procedures for monitoring healthy lifestyles 1.KSC don’t needed 17,1 % 2. KSC needed 69,0 % 3. Satisfactory level of KSC 5,9 % 4. Good level of KSC 54,9 % 5. Excellent level of KSC 29,8 % 1.KSC developed during education 50,0 % 2.KSC developed worked based 59,4 % General knowledge, skills and competences for usage of reporting and monitoring tools 1. KSC don’t needed 2,6 % 2. KSC needed 82,9 % 3. Satisfactory level of KSC 5,6 % 4. Good level of KSC 51,8 % 5. Excellent level of KSC 36,8 % 1. KSC developed during education 34,7 % 2. KSC developed worked based 77,3 % General knowledge, skills and competences in methods for procedures for fostering customers going out of home 1. KSC don’t needed 24,9 % 2. KSC needed 61,6 % 3. Satisfactory level of KSC 14,4 % 4. Good level of KSC 53,9 % 5. Excellent level of KSC 18,4 % 1. KSC developed during education 24,2 % 2. KSC developed worked based 75,5 %

General knowledge, skills and competences for methods of fostering customers social and familiar relations 1. KSC don’t needed 29,5 % 2. KSC needed 57,3 % 3. Satisfactory level of KSC 19,3 % 4. Good level of KSC 54,7 % 5. Excellent level of KSC 9,4 % 1. KSC developed during education 22,2 % 2. KSC developed worked based 71,7 % General knowledge, skills and competences in using ICT for social participation 1. KSC don’t needed 48,3 % 2. KSC needed 40,1 % 3. Satisfactory level of KSC 17,5 % 4. Good level of KSC 39,2 % 5. Excellent level of KSC 17,5 % 1. KSC developed during education 25,7 % 2. KSC developed worked based 58,0 % General knowledge, skills and competences of ICT using for health status monitoring 562634-EPP-1-2015-IT-EPPKA2-SSA

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1. 2. 3. 4. 5.

KSC don’t needed 6,4 % KSC needed 79,5 % Satisfactory level of KSC 10,6 % Good level of KSC 51,2 % Excellent level of KSC 29,7 % 1. KSC developed during education 33,7 % 2. KSC developed worked based 75,0 %

General knowledge, skills and competences in providing the customer with contextualized and personalized information about the network of services he/she can rely on 1. KSC don’t needed 11,5 % 2. KSC needed 74,8 % 3. Satisfactory level of KSC 20,2 % 4. Good level of KSC 56 % 5. Excellent level of KSC 15,8 % 1. KSC developed during education 27,1 % 2. KSC developed worked based 79,5 % General knowledge, skills and competences in basic procedures in medical assistance (eg. make injection, provide drugs, change medications, etc.) 1. KSC don’t needed 1,4 % 1. KSC needed 85,1 % 2. Satisfactory level of KSC 2,8 % 3. Good level of KSC 50,0 % 4. Excellent level of KSC 41,2 % 1. KSC developed during education 69,2 % 2. KSC developed worked based 50,2 % General knowledge, skills and competences for caring with dignity 1. KSC don’t needed 5,7 % 2. KSC needed 80,0 % 3. Satisfactory level of KSC 3,6 % 4. Good level of KSC 41,0 % 5. Excellent level of KSC 49,8 % 1. KSC developed during education 49,0 % 2. KSC developed worked based 69,0 %

General knowledge, skills and competences for managing conflicts 1. KSC don’t needed 19,6 % 2. KSC needed 67,2 % 3. Satisfactory level of KSC 14,6 % 4. Good level of KSC 55,7 % 5. Excellent level of KSC 19,3 % 1. KSC developed during education 24,1 % 2. KSC developed worked based 75,5 % General knowledge, skills and competences for cooperation and networking in multi-disciplinary team 1. KSC don’t needed 7,1 % 2. KSC needed 79,5 % 3. Satisfactory level of KSC 6,1 % 562634-EPP-1-2015-IT-EPPKA2-SSA

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4. Good level of KSC 56,8 % 5. Excellent level of KSC 30,4 % 1. KSC developed during education 27,4 % 2. KSC developed worked based 81,6 % General knowledge, skills and competences in networking and coordination 1. KSC don’t needed 34,0 % 2. KSC needed 52,8 % 3. Satisfactory level of KSC 24,8 % 4. Good level of KSC 45,8 % 5. Excellent level of KSC 7,5 % 1. KSC developed during education 22,4 % 2. KSC developed worked based 61,4 % General knowledge, skills and competences in team working by mobile advices 1. KSC don’t needed 19,4 % 2. KSC needed 69,0 % 3. Satisfactory level of KSC 17,5 % 4. Good level of KSC 44,1 % 5. Excellent level of KSC 22,0 € 1. KSC developed during education 18,2 % 2. KSC developed worked based 72,3 % General knowledge, skills and competences for evaluating customer needs and adapting the service 1. KSC don’t needed 4,7 % 2. KSC needed 81,2 % 3. Satisfactory level of KSC 8,9 % 4. Good level of KSC 55,3 % 5. Excellent level of KSC 28,7 % 1. KSC developed during education 29,9 % 2. KSC developed worked based 80,7 % General knowledge, skills and competences for evaluating customer mental health status 1. KSC don’t needed 10,6 % 2. KSC needed 75,8 % 3. Satisfactory level of KSC 21,6 % 4. Good level of KSC 52,2 % 5. Excellent level of KSC 17,6 % 1. KSC developed during education 43,5 % 2. KSC developed worked based 71,1 % General knowledge, skills and competences in empowering the customer 1. KSC don’t needed 16,0 % 2. KSC needed 71,2 % 3. Satisfactory level of KSC 9,0 % 4. Good level of KSC 61,0 % 5. Excellent level of KSC 18,3 % 1. KSC developed during education 26,0 % 2. KSC developed worked based 75,0 % General knowledge, skills and competences in grief process 562634-EPP-1-2015-IT-EPPKA2-SSA

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1. 2. 3. 4. 5.

KSC don’t needed 19,8 % KSC needed 66,8 % Satisfactory level of KSC 25,2 % Good level of KSC 46,1 % Excellent level of KSC 16,5 % 1. KSC developed during e ducation 36,2 % 2. KSC developed worked based 66,8 %

General knowledge, skills and competences in terminal care 1. KSC don’t needed 22,8 % 2. KSC needed 65,2 % 3. Satisfactory level of KSC 31,3 % 4. Good level of KSC 37,9 % 5. Excellent level of KSC 12,9 % 1. KSC developed during education 48,0 % 2. KSC developed worked based 56,5 % General knowledge, skills and competences for supporting the customer in building up an independent living path 1. KSC don’t needed 4,2 % 2. KSC needed 81,9 % 3. Satisfactory level of KSC 4,2 % 4. Good level of KSC 51,4 % 5. Excellent level of KSC 38,0 % 1. KSC developed during education 39,2 % 2. KSC developed worked based 78,4 %

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