This resource book addresses the issue of integrated care for older people with long-term, complex, multiple needs. The sustainable provision of appropriate care to older people is a challenge for the next decades that all EU member states are facing. There are three main reasons for this challenge: demographic changes, cost containment and empowerment.
Providing appropriate packages of care and services at the appropriate time and place contributes to people’s well being in their old age, in spite of frailty and disabilities. Moreover, having autonomy and responsibility contributes to their quality of life. So integrated care deals with meeting the complex and multiple needs of older people, and with empowering them to live their own lives. It is important that we realise this, while at the same time recognising that not all older people are the same.
Care providers and professionals should not generalise and stereotype older people. For example, the majority of older people prefer to remain at home for as long as possible, and to have a large degree of self-direction. Others simply do not. In the interaction between the professional and the older person, these preferences have to be communicated. This interaction is the core of care, even if the partnership between the older person and the professional is somewhat unequal. Caring is a discipline of human relations, and the key to integrated care is to ensure that these relationships function at their optimum.
It is a challenge to care providers (managers and professionals alike) and policy makers to deliver such care. There are many obstacles in our current care and service delivery systems, as well as in our traditional management styles. This resource book provides insights and tools to assist managers in establishing well-integrated services where they are appropriate. It also contains practice examples, suggestions for further reading, and web links. It is a first step into establishing a body of knowledge on a Europe-wide level on integrated care for older people.
By ‘integrated care’, we refer to a well-planned and well-organised set of services and care processes, targeted at the multi-dimensional needs/problems of an individual client, or a category of persons with similar needs/problems. This concept is developed further in this resource book. For now, it is sufficient to say that integrated care for older people should be built up by elements of acute health care, long-term (health) care, social care, housing, and services such as transport and meals. It should also address empowerment of older persons, to enable them to live their lives as independently as possible.
In this resource book, we use the terms ‘older people’ or ‘clients’ to refer to older people with complex, multiple needs. We do not intend to stereotype older persons as needy people, or people who always have a ‘clientist’ relationship with professionals or informal carers – we simply use these terms to enable readability.
Although the concept of integrated care is increasingly gaining attention, implementing it seems to be complex. Policy structures, legislation and funding are not suited to this type of care. Organisations are based on specific division of labour and tasks, and professionals are trained under a system that rewards specialisation and fragmentation. Nevertheless, older people, their carers and society expect services to provide the right care, at the right time, in the right place. So the challenge of integrated care has to be taken up, and this process has already started.
While working on the issue of integrated care over the past three years, we have learned that various strategies, mechanisms and tools exist, and are actually applied. Examples of supportive policy measures exist too. However, a systematic collection and description of instruments and measures has yet to be started.
The body of knowledge on integrated care is at its very beginning. Research and policy development within the field are addressed in the International Journal of Integrated Care, but this resource book is the first cross-national step towards providing a sound professional basis in the area of management of this type of care within the context of European care systems.
This book was developed by the Care and Management of Services for Older People in Europe Network (CARMEN). This is a thematic network that operates under the auspices of the European Health Management Association (EHMA). It is supported by the European Commission’s ‘Quality of Life and Management of Human Resources’ programme. It is made up of 40 organisations from 11 European countries. These member organisations represent a wide range of stakeholders, including representatives of service users, carers, primary care providers, acute hospitals, care homes, social care providers, purchasers, researchers, consultants and some other members.
The first task of the CARMEN members was to explore the welfare systems and regional and local systems of care provision in European Union member states. They then studied the interfaces between primary care and secondary care (in other words, between home and hospital), between primary care and residential care (home and care homes) and between residential care and secondary care (care homes and hospitals).
Next, they analysed integration at three levels: client level, organisation or network level, and policy level. They based their analyses on literature reviews, a members’ questionnaire, vignettes, structured analyses of good practice, input from external experts, and discussions among CARMEN members. One group worked on quality management and evaluation. The network also developed a website, as a means for internal and, at a later stage, external communication, and as a portal to relevant links.
This publication was developed as a result of this knowledge and experience. The topics were established and discussed in subgroups and plenary sessions, and members and managers (as non-members of CARMEN) critically reviewed drafts, both in meetings and by email or through the website. The network plans to develop and update the resource book on a regular basis. This will involve adding new chapters and examples, and organising meetings to refine the knowledge presented here. The network also welcomes any organisations interested in localising the resource book so that it applies to the situation in their country (see Geographical spread of content).
The resource book is primarily designed for managers of care-providing organisations, and for managers and officials responsible for commissioning long-term care for older people. The resource book addresses the main concepts, questions and considerations that a manager needs at strategic and tactical level. It provides an overview rather than a detailed account, because it aims to support managers in taking the right decisions while giving direction in developing and implementing services, mechanisms and instruments. More detailed information, and information on more operational issues, are available in the form of references to other publications, web links and case studies.
This resource can be read from cover to cover, but is also designed to be dipped into and out of according to the reader’s priorities. It is written in a condensed style, to enable you to quickly grasp the issues. Each chapter is written to a similar format, with some or all of the following headings:
Case studies and practice examples are also provided, and each chapter ends with a ‘key points’ section summarising the main topics addressed in the chapter.
The book is available in hard copy and has also been adapted for the web, available via www.ehma.org. This means that readers can download, photocopy and distribute the resource book, or parts of it, as often as they like. It is not prohibited – on the contrary, we welcome and encourage it. Additional specific background information, such as practice examples and web links, is available at the EHMA website (www.ehma.org).
This resource book is the very first step towards establishing a body of knowledge on integrated care for older people. In this first edition of the book we have covered a selection of particularly topical themes. CARMEN and EHMA intend to form a special interest group to refine and update it, and add new case studies and web links. The network also hopes to include sections on key topics, such as finances and capacity management, when sufficient resources become available.
For information on integrated care and policy development, see Policy Framework for Integrated Care For Older People, published alongside this resource book. This framework can be used at national level, covering basic considerations and policy requirements that have been determined as important in the CARMEN meetings and analyses.
In its present form, the resource book addresses integration activities that managers can influence, and mechanisms and instruments that they can apply. The basic elements of integrated care are dealt with in chapters 2–7:
These basic elements of integrated care require a number of factors to enable them to work effectively. These are covered in chapters 8–10:
Finally, the processes involved should be supported by the following factors, examined in chapters 11–13:
Two further issues are also of importance at this stage: financial management and capacity management. We are hoping to address these in a later edition of the resource book.
At a general level, the resource book is applicable throughout Europe. However, at national level, adaptations may be necessary. The EU countries have different welfare regimes, and the dynamics within each country are partly determined by its policy system. For these reasons, we encourage any national organisations that have participated in CARMEN to adapt this resource book to fit their respective national context, and to publish the results on the EHMA website.
The socio-political literature makes a number of different classifications of welfare regime. Within the European Union, the following main types can be distinguished:
Precisely how services should be integrated depends partly on which system they sit within. However, the general mechanisms and instruments are very similar across the member states.
This resource book is intended as a dynamic and developing source of information and support for managers and policy makers responsible for delivering services for older people. We welcome comments and constructive criticism, and especially examples of good practice that illustrate the issues explored in the book, and would be delighted to hear of any ideas and suggestions that contribute to our work. CARMEN is a network of people who share a passion for enhancing the quality of care for older people through better-integrated services. If you would like to contribute to its growth and the development of ideas, visit the EHMA website at: www.ehma.org.
Dr Jan Coolen, who was at the Netherlands Institute for Care and Welfare (NIZW), and who is now at Zorgverzekeraars Nederland, was Scientific Director of the CARMEN project during the first sixteen months. It was largely his vision that formed the basis of the project proposal and the work of the project partners in those initial months. We are all greatly indebted to him for his contributions.
The editorial consultant, Eleanor Stanley, and Maeve Royston, EHMA’s Project and Development Manager, have laboured long and hard to prepare the final publication, and we are all most grateful to them for their efforts.
Petra Wilson, EHMA’s Associate Director for EU Affairs, gave invaluable advice on a wide range of European issues, while Marie Ní Mhurchú, EHMA’s office manger, managed the complex administration of the project with consummate skill.
The European Commission Project Officer, Gesa Hansen, and the Project Technical Assistant, Dora Groo, have both been unfailingly helpful and encouraging, and their support has been enormously appreciated.
Finally the authors and editors would like to thank the members of the CARMEN network who have laboured over a three-year period, first to understand the differing approaches across Europe, then to learn from each other, and finally to distil their learning into the ideas contained in this resource book. The journey that we have shared has been exciting, illuminating and occasionally frustrating, but certainly of great value to all of us. From these small efforts, we can build a Europe in which people value the benefits of different approaches and perspectives – a Europe that will prize the contributions of its older citizens to the common good – and a Europe that will care for its older people with gratitude and generosity. (For details of all CARMEN members, see CARMEN participants.)