A Slovenian model of integrated care for older people can offer solutions for NHS services
Services need to adapt to meet the needs of our ageing population. A model of care from Slovenia provides an innovative approach to caring for older people
Helen Jones, MA, PGDE, BSc, RN, is senior lecturer, University of Worcester; Steve Wilding, BSc, RMHN, is community psychiatric nurse, Worcestershire Mental Health Partnership Trust.
Jones H, Wilding S (2009) A Slovenian model of integrated care for older people can offer solutions for NHS services. Nursing Times; 105: 49-50, early online publication.
The population in Britain is ageing and creating a burden on healthcare that will require the NHS and social care to deliver new and innovative strategies. This article outlines a visit to Slovenia to view a model of care which fits well with the Department of Health’s integrated care agenda for long-term conditions and care of older people.
Keywords: Ageing population, Integrated care, Older people
- This article has been double-blind peer reviewed
- The ageing population is having and will continue to have a big impact on nursing care.
- Nurses need to consider how they can provide appropriate yet individualised care.
- The profession also needs to promote dignity in care, particularly in vulnerable older people and clients with mental health needs.
- Greater thought should be given to the integration of social and nursing care.
Britain is experiencing an extraordinary demographic transition due to the post-war “baby boomers” now reaching retirement age (Age Concern, 2008). Figures from the Office for National Statistics (2009) show the number of people aged 85 and over is projected to more than double over the next 25 years, from 1.3 million in 2008 to 3.3 million by 2033. With significant increases predicted in the number of over-65s with dementia, coronary heart disease and osteoporosis by 2025 (Telegraph.co.uk, 2009), those providing care for older people face a major challenge.
The National Service Framework for Older People (DH, 2001) encouraged the eradication of age discrimination and promoted the importance of supporting person-centred care within newly integrated services, with particular focus on integrated mental health services. Translating these nationally supported standards into local delivery presents challenges for the NHS, as the present model of care segregates social and nursing care when older people begin to need assistance with activities of daily living.
In November 2006, the DH launched a Dignity in Care campaign, which initially focused mainly on dignity for older people. From August 2007, the campaign was extended to mental health services where it focused on tackling stigma, the therapeutic environment, safety and privacy, extending rights to advocacy and older people’s mental health.
The Dignity in Care campaign invited providers and commissioners of services and members of the public to volunteer as champions to “take forward a dignity in care social movement”, raise the profile of dignity in care, challenge bad practice and share experiences and expertise (DH, 2006a).
Lessons from abroad
Britain is not alone in facing this burden of care and much can be learnt from other European countries running initiatives mirroring those of the NHS. This article describes a visit to Slovenia to investigate a seamless model of care for those requiring minimal assistance through to high dependency needs and eventually end-of-life care.
According to figures from 2003, the population of Slovenia is estimated to be just under two million, with approximately 14% of the population over 65 years.
The visit to Maribor University, Slovenia, was funded by an Erasmus (European Region Action Scheme for the Mobility of University Students) grant.
Staff at Maribor University were welcoming and we were able to share significant insights into the similarities and differences in the delivery of student nurse training despite the language barrier.
The visit included an appointment at an elderly care facility and the model of care promoted there was innovative and creative. The model of care was also financially prudent and provided integrated holistic care for residents. We believe it is an approach which the NHS should consider in response to the National Service Framework for Older People (DH, 2001) and the NHS Next Stage Review interim report (DH, 2007a), which both promoted care in the community.
The launch of the “whole system demonstrators” approach to integrated health and social care (DH, 2008; DH, 2007b) further encouraged healthcare providers to shift care from hospital by supporting people to retain independence in the community. These proposed integrated approaches to care can be seen in the Slovenian model.
Sunny Dale (translated title) is a concrete tower block, which, we were told, had previously been used as offices during Tito’s communist regime. However, about a decade ago it was converted into an elderly care facility for private and state-funded residents.
The over-arching philosophy of this establishment fits in with the National Service Framework for Older People (DH, 2006b; 2001). The NSF aims to ensure that older people receive appropriate and timely packages of care which meet individual needs regardless of health and social service boundaries.
The set up of the home ensured that residents requiring assistance with health and social care were able to remain in one place throughout their lives, with their varying care needs being met under one roof. If the levels of care or residents’ needs changed, they remained at Sunny Dale because their changing circumstances and care requirements could still be met.
This flexibility is evident in the structure of the care facility (Box 1).
Box 1. Sunny Dale facilities
Floor 8: Private residents in single rooms
Floor 7: State-funded residents in shared rooms
Floor 6: Residents with acute mental health problems
Floor 5: Residents with mild to moderate mental health problems
Floor 4: Patients requiring nursing care (state-funded and private)
Floor 3: Patients requiring nursing care (state-funded and private)
Floor 2: Patients requiring assisted living
Floor 1: Patients requiring assisted living
Ground Floor: Communal space and clinic areas
Basement: Occupational therapy and social space
Care facility layout
The layout in Box 1 illustrates the range of health and social care provided at the home. On the top floor are single rooms catering for fee-paying residents with varying degrees of physical disability but who do not need a high level of nursing care. We visited one woman on this floor who was in a wheelchair and needed assistance with mobility but she had a significant number of aids to help her to be relatively independent. The seventh floor is similar, although residents on this floor share rooms and are funded by the state.
Floors 5 and 6 are devoted to the care of residents with mental health problems, particularly those with dementia and difficulties in cognitive functioning. These levels are staffed 24 hours a day by healthcare assistants. The floors are accessed by lifts requiring a code to move off the floor, providing a higher level of security for residents.
Floors 3 and 4 are devoted to providing high levels of nursing to patients with severely reduced mobility and acute care needs. The majority of patients on these floors are confined to bed and care is provided again by healthcare assistants with the support of a qualified member of staff.
The two lower floors offer sheltered-housing style accommodation where older people experience assisted living. They have their own rooms with en suite and cooking facilities. This fits with the NHS Modernisation Agency’s (2009) commitment to promoting self-care in the management of long-term conditions agenda.
The ground floor has clinical facilities where nurses and doctors can conduct clinics and provide treatment. Residents can also be given communal healthcare such as flu vaccinations, to prevent the spread of infection. This is an important element of community living, to ensure disease prevention and health promotion (Gaughran et al, 2007).
In the basement is a social space where residents meet and there are restaurant facilities providing meals for those who need them. Green et al (2008) emphasised the importance of providing stimulation for patients and clients. In Sunny Dale, the occupational health facilities organise three sessions a week for residents to do a range of activities based around arts and crafts. These sessions are arranged by floor so that residents with mental health problems who require more supervision are catered for on a different day to those who need less help.
In total there are 160 residents, cared for by three qualified nurses and 15 healthcare assistants, and one social worker who links with community social workers. There are also three doctor sessions per week.
Staffing levels depend on the nature of the care provided on each floor and needs assessment. Although staffing levels appeared to be minimal, there was no evidence of staff being under strain and the atmosphere was relaxed, friendly and competent.
The home also arranged organised social outings for the independent living clients and had its own singing group giving regular performances to other residents. This is, we were told, an important part of Slovenian culture for the older generation. Intellectual and spiritual needs are met through a fully stocked library and chapel offering weekly services.
Sunny Dale is financed partly from the government and partly by private income generation. Interestingly, charges for medications varied with some being provided by the state but with residents or their relatives forced to pay for some of the more expensive drugs.
Comparison with an NHS model
The integrated care provided at Sunny Dale has similarities with the definitions of care outlined by the NHS Modernisation Agency (2009) but with the unusual feature of being provided in one facility.
As stated in the Modernisation Agency’s model most people (70-80%) with long-term conditions can care for themselves with minimum input from health and social services (Fig 1). They represent the bottom floors of the Sunny Dale model – that is, those who would be defined as living in a sheltered housing type situation.
The middle layer includes high-risk patients who need more active disease and care management from professionals. This would correspond to the clients with mental health problems and those on the two upper floors at Sunny Dale who needed assistance.
Finally, in the top level of the pyramid are patients with highly complex needs. These patients are usually aged over 65, and represent a small proportion of the population. This category can also be identified in the care provided at the home as those requiring a high level of nursing care and those reaching the end of life.
Sunny Dale provides an inspirational approach to the care of older people requiring varying levels of assistance. The home is a community which provides autonomy for those capable of caring for themselves but is also able to respond to their needs if and when residents deteriorate.
The model we saw at Sunny Dale would appear to offer solutions for the NHS agenda for care of older people. If nurses are to embrace the fundamental principle that “the practice of caring is central to nursing” (Watson, 1979) then we need to acknowledge that this type of seamless approach is a valid one.
This model should be explored in the new initiatives for care delivery and should be viewed as an opportunity to blur the existing boundaries between health and social care.
- As the population in Britain is ageing,
- NHS and social care services are facing huge challenges in tackling this increased burden of care.
- National standards for caring for older people were laid out in the National Service Framework for this group (DH, 2001).
- More recently, the DH launched a Dignity in Care campaign, which aims to promote best practice.
- More work is needed to translate these models into everyday practice.
Age Concern (2008) The Age Agenda. London: Age Concern.
Daily Telegraph (2009) Number of dementia and heart disease sufferers to stretch NHS to breaking point. Telegraph.co.uk.
Department of Health (2008) Whole System Demonstrators. London: DH.
Department of Health (2007a) Our NHS, Our Future: NHS Next Stage Review - Interim Report. London: DH.
Department of Health (2007b) White Paper Pilots: Whole System Long-term Conditions (LTC) Demonstrator Programme. London: DH.
Department of Health (2006a) Dignity in Care Champions Network. London: DH.
Department of Health (2006b) A New Ambition for Old Age: Next Steps in Implementing the National Service Framework for Older People. London: DH.
Department of Health (2001) The National Service Framework for Older People. London: DH.
Gaughran F et al (2007) Flu: effect of vaccine in elderly care home residents, a randomized trial. Journal of the American Geriatrics Society; 55: 12, 1912-20.
Green J et al (2008) Older people’s care experience in community and general hospitals: a comparative study. Nursing Older People; 20: 6, 33-39.
NHS Modernisation Agency (2009) Chronic Disease Management: Population Management. London. DH.
Office for National Statistics (2009) UK Population Projected toGrow by 4 Million Over the Next Decade. London: ONS.
Watson J(1979) Nursing:The Philosophy and Science ofCaring. Boston: Little Brown.