To improve integrated care for older people, it is important to have the right number of staff with the appropriate knowledge, skills and motivation to deliver services with expertise, empathy and efficiency. New or different professional roles, competencies, values and attitudes may have to replace the more traditional ones, as they do not necessarily fit the requirements for integrated care service provision. Working across professions and organisations, and taking on a client-centred perspective, are only two of the challenges that need to be met. New structures or organisations may have to be set up, new partnerships created or old collaborative arrangements reframed.
Delivering this change puts the whole workforce to the test, in terms of knowledge, flexibility and attitudes. This requires commitment throughout organisations, from senior management to frontline staff. Managers need to facilitate changes, support and motivate their staff, and forge new partnerships with other organisations, as well as with service users. They face this challenge against a demographic backdrop of an increasingly larger and diverse older population coupled with a diminishing influx of young people into the labour market. The same demographic trend also puts an extra strain on the public and private finance available to deliver the appropriate services.
This chapter looks at the key building blocks for human resources that need to be in place to manage and deliver integrated care. It provides pragmatic examples and tools, and aims to help managers take a further step towards building an appropriate and sustainable workforce.
The overall picture of the human resources that contribute to the provision of care for older people has many facets. It may include professionals, lay people, volunteers, paid employees, friends and family, and workers from the so-called ‘black market’, which may also include illegal immigrants. In order to arrive at truly integrated care provision, communication and collaboration with all these formal, informal and unofficial ‘care resources’ is important, particularly in countries where substantial gaps exist in the regular services available or where direct payments enable clients to buy their own care packages.
While acknowledging the reality of the diversity of human resources in the care domain, this chapter focuses on the formal workforce domain only. Here, the term ‘workforce’ includes all staff employed by care-providing organisations and agencies, but particularly those employees actually involved in care delivery, as opposed to technical, financial and administrative staff. The role of informal carers is certainly recognised as being very important, but for the purpose of this chapter they are not considered to make up part of the workforce. However, the scope of the chapter does include professional support for carers.
Integrated care provision is very much a service of people, for people – a service reliant on human resources. No matter what financial means, modern buildings, or state-of-the art equipment your organisation may have available, it is your workforce that can make service delivery take place, and will indeed make it take place, provided there are sufficient supportive conditions in place. It is your staff who do the actual caring, engaging with older people and their carers, and who deliver your services at the frontline. Last, but not least, it is also your frontline staff that function as your primary eyes and ears – receiving and transmitting first-hand feedback on the quality and efficiency of local service provision, and functioning at the heart of your ‘learning organisation’.
The very fact that your workforce is functioning within an integrated setting may present some specific concerns to your staff. They may be working under management from several different organisations, or may have to take their lead from a manager who is not formally employed by their own organisation. They may find that their colleagues from other agencies do not have equivalent qualifications and yet are being given similar, or even more senior, responsibilities. Wages and benefits packages may differ across organisations, as can professional standards and work cultures. In addition, staff may be asked to uproot from the location they are working from and to settle into a team with new colleagues.
Of course, the same coin also presents a more positive side. Bringing together different types of services and professions, integrated care arrangements present more opportunities for horizontal staff mobility. It also has high potential as a creative environment for professional growth and cross-sectoral learning.
A well-managed and supported workforce will be beneficial for clients, but also for managers. For managers, important outcomes will include:
For staff, benefits will include:
To achieve the outcomes described above, and to deliver high-quality, efficient integrated care, staff and management alike need to shed their more traditional mindsets and acquire new skills and knowledge. Integration of services often implies that boundaries between provider organisations will become increasingly blurred. For this reason, sharing workforce-support mechanisms – including training – across organisations may be not only appropriate but also could be instrumental in advancing teambuilding.
There are, of course, many different ways to support and train staff, or to identify new roles and embed them in the whole system of service provision. Your preferred approach may depend on the type of organisational integration you want to achieve. This may vary from a ‘linkage’ model to co-ordination of services, through to full integration, or even a merger (Leutz 1999). Integrated arrangements may take many forms, as do problems challenging the process of integration. The same holds true for integrated teams. All these issues will reflect on the training needs within your own organisation as well as those of your partner organisations.
Prior to the design and development of training, the organisations within an integrated care network will benefit from mapping all their training needs and developing a joint strategy for recruiting and training, or retraining (Audit Commission 2002). In addition, periodic review meetings need to be held to make sure that knowledge and skills are kept up to date and that they still adequately match the services needed.
In looking at the needs of the workforce with regard to training, the person-centred approach can be useful in integrated care networks. This approach takes the individual client as a starting point to identify and map what services and staff are needed, what new roles need to be developed, and what training is necessary. It encourages process-oriented thinking across traditional boundaries of the various service organisations involved (Schwartz et al 2000). The system-level approach is similar, but broadens the perspective to include the integrated family network. This approach looks at how treatment, care and support are provided to both client and informal carer. Thus, it perceives the carer as part of the integrated team – in other words, a ‘colleague’ of the professional staff involved. It also takes into account the carer’s support needs in terms of care provision, as well as in a more personal respect (Tjadens and Pijl 2000).
In operational terms, supporting the human capital needed to deliver client-centred integrated care implies:
The specific demands that this makes on management leadership are explored in more detail in Chapter 10.
Seamless care delivery is often laid in the hands of interdisciplinary teams. However, the cultures of health care and social services are not very supportive of this kind of teamwork (see Chapter 7). When looking at implementing changes in these cultures, managers need to think about training, supervision, legal safeguards (accountability and responsibility for a procedure or activity), planning, and resources (Dargie et al 1999). For more information on working towards a joint vision and adopting client-centred attitudes, see Chapter 9.
However, as could be learned from transforming service provision and introducing integrated quality management in local services in Finland (Vaarama et al 2004, Valvanne 2002), changing vision and practice is a gradual and challenging process of learning, training and implementation. It requires the inclusion and acceptance of the staff at all levels within each organisation. Everybody’s input should be valued in this process as shared vision is an anchor for change.
As has been explained throughout this resource book, traditional professional roles and expertise do not necessarily fit the requirements for the provision of integrated care services. Because of this, integrated care has proved to be a very creative breeding ground for new professional roles. The work areas of many of these new professionals are described in more detail in other chapters. They include elderly or peer advisers, case managers, information managers, advocacy workers, needs assessment specialists, quality monitoring specialists, service planners and team managers. Three other examples – integrated services officers, service network co-ordinators and logistics service producers – are explained in detail below.
This type of professional role was developed within the context of sheltered housing for people with dementia. In this arrangement, one professional provides all the services needed to support the clients in living independently in their communal home. This includes support with activities of daily living and domestic activities such as cooking and cleaning, caring, social support, linking with and supporting relatives and friends, and logistic management. In making the shift from a more traditional approach to this type of integrated service, four key steps can be identified (Krijger et al 2002):
Local integrated care service networks need to be co-ordinated. A service network co-ordinator provides structure to the network, and manages its joint efforts. He or she enables the network and stimulates its participants to work towards achieving common goals or solving common problems. The co-ordinator also monitors process and progress. Expert knowledge, process skills, natural leadership qualities or available resources may all play a role in choosing an appropriate co-ordinator for the network. The co-ordinator also needs to be trusted by all parties. Democratic participation in appointing a co-ordinator is important as the network should be based on equality of partners (Goumans and Tamsma 2003).
While case managing care services is a fairly accepted phenomenon, older people may also need help in organising various domestic services to help out with activities of daily living such as shopping and cleaning.
The city of Helsinki, Finland, initiated logistics services in 2002, in response to a client-satisfaction survey with regard to the city’s care services. Recipients of Helsinki’s home-care services were fairly positive about the quality of care overall, but they did come up with numerous suggestions for improvement. The most important ideas all had to do with the logistics of bridging the gap between demand and supply:
Source: Valvanne (2002)
On average, informal carers provide by far the most care to their family members, friends or loved ones. Carers may need support with many different aspects of their responsibilities, including easing of their workload, advocacy, information and advice, practical and instrumental support, financial support, emotional support, forms of respite, and/or the opportunity to participate in policy or practice-oriented inter-sectoral networks. Examples of support organisations for carers may be seen in many countries, including Ireland, in the national carers’ association ‘Caring for Carers’, and Finland, with the Association of Care Giving Relatives and Friends. In addition, regular care-providing agencies or research and development organisations may run support and training programmes for carers (Banks and Cheeseman 1999).
In Finland, the Association of Care Giving Relatives and Friends has developed a number of projects providing training for carers. The first provides training for peer group leaders for carer groups, in co-operation with 13 patient or other social sector associations. The scheme provides peer group activities to find new ways, and to promote old ways, of providing emotional support for family caregivers.
The second project trains volunteers and professionals to support carers in difficult situations and helps them to discover the best ways of offering this support. Two smaller projects focus on supporting carers before the care recipient moves into institutional care, and supporting carers of short-term patients.
Source: Autio (2002)
As a broad concept with regard to integrated care, ‘capacity’ is certainly not just about ‘beds and buildings’. It can refer to a whole range of resources, such as finance, leadership, knowledge and skills. Capacity is required at qualitative and quantitative levels, and within different entities, including the whole system of services, organisations, personnel, and the individual receiving care. If capacity is ‘the ability to carry out stated objectives’ (Goodman et al 1998), then capacity building is the process or activity that improves this ability. It should also contribute to sustainable performance (LaFond et al 2002).
Mapping is the initial step in the design of capacity-building interventions: it provides the link between capacity and performance. The issue of mapping services is discussed in more detail in chapters 10 and 11. However, with regard to mapping skills and competencies of the workforce, management and staff both have a role to play.Management should develop proposals and solutions in relation to the key workforce issues by:
Fig 8 shows the main areas of quality requirements in home care. Staff should map their individual skills according to the quality requirements identified by the management. Development and training plans for individual staff, for teams, for the whole organisation, or for teams working across organisations can then be drawn up.
Source: Valvanne (2002)
In addition to more ‘technical’ professional competencies, staff members involved in delivering integrated care within the context of multi-disciplinary teams need to be responsible, communicative, able to perform an assessment, and able to work beyond professional boundaries and across a range of organisations. Other competencies that are particularly relevant here include communication and problem solving skills, and creativity.
The elderly adviser is one of many new professions developed to meet the demands of integrated care delivery. The Netherlands Institute for Care and Welfare developed a formal specification that included the following competencies:
Source: Lammersen and Phillipi (2003).
Managers across the European Union are currently facing the challenge of staff shortages. This is due to a variety of factors, including demographic trends. Across Europe, a range of approaches are being applied to tackle these shortages. These include running media campaigns aiming to improve the image of care work, recruiting from under-represented groups, and improving recruitment strategies, employment conditions and access to – and the level of – education and training.
Of course, recruiting professional staff will first and foremost focus on people who already have the required professional or vocational qualifications and/or can demonstrate recent work experience. However, without losing sight of the importance of regular professional standards and qualifications to deliver high-quality services, building the integrated teams that are needed to deliver integrated services can provide an excellent opportunity to recruit staff with supplementary skills and expertise. Flexible and creative people who are able to help a team ‘gel’ and to overlook old ‘demarcation lines’ could, of course, come from many backgrounds. For this reason, you may consider recruiting staff with less conventional qualifications.
Another creative way to draw in newcomers is to look for people who are very motivated – and, of course, suited for the job – but lack formal qualifications or recent work experience. People who have not been in paid employment for a long period of time – for example, through a history of unemployment, illness, caring or parenting – could be encouraged to re-enter vocational training if your organisation offers to accredit their prior learning as well as their organisational or caring skills learned in the domestic environment.
In collaboration with local social benefits agencies, the Netherlands Institute of Care and Welfare set up ‘Working and caring’, a project to improve the competence of long-term unemployed women and, to reduce loneliness among older people. The scheme recruited women from deprived communities with a history of unemployment, and trained them in a group setting to reach out to, visit and support older people suffering from loneliness. This project contributed to the quality of life of the older people involved as well as increasing the self-esteem and employability of the trainees.
Source: Tenhaeff (2003)
As staff shortages increase, recruitment of staff from other countries may become a viable option. Freedom of movement of people, goods, capital and services is being promoted within the EU internal market, and legal arrangements regarding the mutual recognition of professional qualifications relevant to health care – such as doctors and general care nurses – will become more simplified through new European Community legislation (European Commission 2002). With the accession of ten new countries in 2004, the European Community has widened considerably, with many different implications for all involved (Irwin 2001, Albreht 2002, Zajac 2002).
Certain skills, such as language skills or familiarity with the professional culture in the host country, may influence the focus of international recruitment. The UK, for instance, predominantly looks to the Philippines, South Africa and Australia to help solve its staffing problems (Buchan 2002).
Whether recruiting from one’s own country or from abroad, it is important to involve older people, or their staff representatives, in the recruitment process. This can either happen indirectly, by asking them to identify what is important to them in a professional care provider, or directly, at some point in the recruitment procedure itself.
Across sectors and organisations, staff training programmes need to include a range of themes. The interaction, relationship and dialogue with the older person as a client should be the basis of the training. The same holds true for the awareness that working together with all key players in the care system (including the client and their informal carer) will lead to more efficient, better-quality care.
Acquiring a full understanding the concept of integrated care and its consequences for their own tasks, functions and competencies will help staff develop a shared vision. In addition, interdisciplinary learning enables working across professional and organisational boundaries: it should be a focus as well as an objective of the training programme. Developing a common language is an essential tool for integrated working. Finally, in team-building programmes, special emphasis should be put on communication between staff from different professional backgrounds, as well as between clients, carers and professionals.
Working in an interdisciplinary team often implies taking over tasks from other professionals – both horizontally as well as vertically – which means an extension of one’s tasks. As a consequence, it might be wise to provide staff with some generic training during the first stage of the implementation period (Dargie et al 1999), or to set up a job-rotation programme to develop the necessary skills. Recognising that professional and organisational identities and boundaries may be persistent, managers are recommended to provide incentives, such as accreditation points or certificates, for staff taking part in training.
Across the European Union, countries are seeing their populations becoming increasingly diverse. As client-centredness and service delivery within older people’s own living environments are key to integrated care provision, care needs to be provided in a culturally sensitive way. Thus training programmes should address issues related to diversity in terms of issues such as language, culture and lifestyle. In some European countries, specific services for black and minority ethnic communities have already been set up.
The needs of the care system do not always match the output of the education system. Basic vocational training courses that directly prepare students for practical work are becoming less popular as many aspire to achieve grades in higher education. This puts pressure on the demand for staff providing domestic and hands-on care services. On the other hand, care providers may need more personnel with university-level education to keep up with the development of new methods of working, treatment, care and support. In Sweden, statutory care providers – in other words, representatives of local government – are now working with the education system to improve the match, by creating capacity in the university system for one-to-two-year training courses for assistant staff in health and social care for older people (Lofgren 2001).
Some problems in the development of inter-agency working are due to differences between staff in attitudes, background and professional language. In Finland, this is being addressed by the development of a basic level of education for those wanting to work in elderly care in either the health or the social sector. In the long run, any staff working at primary level should ‘see and hear’ their older clients in the same way and share a common language (Rissanen 2001).
Staffing issues are addressed throughout various chapters in this resource book. Without negating the relevance of specific technical expertise, such as integrated needs assessment, the overall message that emerges is the importance of ‘soft’ competencies, which rely heavily on social and emotional skills. Integrated care has very much to do with to attitudes, values, holistic approaches, interpersonal skills, the ability to work in teams and across organisations, and creativity. Integrated care is also about listening to clients, and teaming up with them and with their carers. It needs to be carried out by a learning organisation that embraces change and fosters open communication along horizontal lines.
All staff need to be involved in the shift towards client-centred integrated working and must perceive their contribution to be recognised and validated. Integrated working is well and truly a team effort: a process that needs to be ‘owned’ at all levels, within and across organisations. Encouraging bottom-up input into this process is essential but should not cover up the importance of middle-management involvement and senior management support and leadership.
As this chapter is dedicated to building blocks for human resources, it is important to look at staff requirements for delivering the workforce agenda, in terms of support, training and developing new roles. Developing and sustaining integrated care services is not a quick fix or ‘one off’, but a continuous process that needs time, and benefits from periodic review. Setting aside adequate resources in terms of time, finances and people is essential and should be perceived as a long-term investment. Creating a special executive management portfolio may help to support the process and practice of integration, and to acknowledge its importance for the organisation as a whole.
Service integration and networking often need one or even several ‘integration or social entrepreneurs’ to make the whole integration process happen and to keep the ball rolling (Hudson 2003). They should have a strong commitment to change and will be skilled at mapping and developing policy networks, identifying where linkages are possible, and able to build coalitions and alliances.
They will have rather different tasks from those with conventional line-management functions within organisations. These will include:
(Hudson 2003)
In facilitating and supporting their staff, managers need a variety of competencies (Audit Commission 2002, Adams 2003). These include:
In a study to find out what types of behaviour among leaders may enhance innovative behaviour of co-workers, de Jong and den Hartog (2003) came up with a similar list of traits that were found to be effective:
They also found that excessive monitoring and target setting could impede innovation, as this could discourage staff from taking risks and may make them feel safer sticking to routines.
Although they could substantially contribute to the development of integrated care (see Supports), national policies and jurisdiction may also function as substantial obstacles. They can inhibit services within and across sectors from certain forms of collaboration – for example, with regard to joint employment arrangements or pooling budgets. Formal national standards or requirements may also frustrate experiments with new professional roles or the more structural incorporation of these new professionals in your workforce.
A shortage of data about the population that the integrated team serves can also be a substantial hurdle, particularly to your planning abilities. Furthermore, data may be available or accessible only within the sector in which the team is working, which could lead to insufficient insight into the clients’ living conditions, social and financial resources, or specific needs with regard to culture or language.
As far as management skills are concerned, getting things right in terms of workforce has much to do with good leadership and managing cultural change. National policies can be helpful or enabling in developing and supporting an integrated workforce. Particularly helpful are inter-sectoral policies that acknowledge the increasing demand for client-centred integrated care and make provision for this through:
To conclude, the following issues seem essential in building an appropriate and sustainable workforce and thus in supporting ‘human capital’ to deliver client-centred integrated care:
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