How to foster an integrated health and social care centred on the individual in a local environment

14 Mar

SUSTAIN is a Horizon2020 European Project related to integrated care for older people that live at home with complex health and social needs. Thirteen initiatives from seven European projects participate in it.

It is a project whose aim is to improve a range of things including the care centred on the individual, the coordination of teams of professionals, the preventive nature of care, safety and efficiency.

In Catalonia, two initiatives (Social and Health Integration of Sabadell Nord and the Programme for complex chronic and advanced patients and the geriatric population of Osona) have participated in the design and development of projects for improvement which have been assessed by AQuAS (you can read the report and article here).

On 23rd January, 2019, professionals involved in the groups that are the driving force of the two local initiatives (Sabadell and Osona) of integrated health and social care – family doctors, workers and social workers, nurses, geriatric and management personnel- met at AQuAS in their first joint meeting.

(SUSTAIN team Sabadell, Osona and AQuAS in Barcelona

The professionals were able to share thoughts on one question: What remains of the SUSTAIN project in the territory?

This was the starting point to identify specific actions that can make the projects sustainable and to also comment on aspects for improvement beyond the projects.

The aim was to identify opportunities within reach of the local initiatives themselves that could serve to generate a more favourable environment for integrated health and social care centred on the individual, both preventive and reactive in nature.

From the brainstorming that was done, a multitude of local actions can be derived with which to drive integrated health and social care centred on the individual. Let’s look at it in detail:

  1. Prioritise at a population level Delimiting a population group for which it is deemed most important to apply the new PIAI method (Individualised Plan for Integrated Care), so that efforts can be concentrated on this group until the context allows for scaling up to the entire population of 65 and older. One possibility would be the older people who live at home with complex health and social needs who at present receive home-based healthcare, or for those cases known by primary healthcare but are not beneficiaries of home-based social care. This would be done in order to eliminate the barrier limiting access to social services or because there is a lack of awareness of these social service
  2. Provide continuity in coordination between sectors, while taking into consideration the suitability of the new PIAI method for each individual case Continuing with periodic meetings of the team of professionals in charge of the multidimensional assessment of needs so as to plan an individualised and integrated health and social care (at least of the triad of primary care, family medicine-nursing-social work). These meetings, held on a monthly basis, would enable the teams to consider who, among those users visited recently (in primary care centres, at home, at local social services, at intermediary care in the case of Osona), would particularly benefit from the integrated and participative approach of SUSTAIN, with the possible introduction of changes or objectives to improve their care and their quality of life.
  3. Inviting professionals that have not participated in SUSTAIN to use the new PIAI method, giving these professionals the necessary tools (time, training) so they can familiarise themselves with the approach of integrated health and social care centred on the individual. With this in mind, there is talk of the importance of “maintaining the spirit of SUSTAIN” and in gradually getting the most reluctant professionals more involved in introducing changes to their way of working.
  4. Carrying out an analysis of the different capacities and responsibilities of each professional in primary care teams (family medicine-nursing-social work-social health work), and sharing out roles and responsibilities ad hoc, which can enhance the skills of each individual. This could mean that professionals who officially occupy the same position (for example, family medicine) would become specialised in one or another type of care (emergency, development of the PIAI, specific pathologies), and it would mean accepting that not all professionals with the same position need do the same: “one-size-only professionals are not needed”.
  5. Enhancing the figure of the spokesperson in a healthcare team, both when dealing with a user as well as an internal coordinator of a team, emphasising that the user has a team with professionals that interact with each other in order to provide solutions to their different needs as quickly as possible. The emphasis is on the opportunity that workers and social workers have in acting as liaison officers between primary care, local social services and community resources while at the same time coordinating actions which are contained in the PIAI.
  6. Analysing how the figure of the social and health worker can best fit in In the case of Sabadell, this figure has only been incorporated very recently. An analysis will need to be carried out with the entire group of professionals that intervene in care but especially with the social workers (under contract with local social services, socio-health workers or social workers specialised in intermediary care). This will be done in order to understand their capacities and perspectives of what function each professional should have bearing in mind their particularities and the specific environments in which they work (for example, specific tools and procedures they can apply, what information systems they have at their disposal or what other professionals they are in direct contact with).
  7. Set up safe and respectful local systems with the LOPD (Spanish personal data protection law) in order to exchange the minimal information necessary to carry out a joint multidimensional assessment and to share the PAIAs among the most important professionals in each case. The example of Integrated System of Health in Osona (SISO) is mentioned, which enables primary care professionals to see which users are admitted in the hospital centres that make up the system, or the mechanism foreseen by the County Council of Osona to enable social health workers employed in health centres to consult the degree of dependency of a user.

We end this post by commenting that this week we participated in the final conference of the project in Brussels.

Representatives of the Osona SUSTAIN team, Sabadell and AQuAS in Brussels

Post written by Jillian Reynolds, Lina Masana, Nuri Cayuelas and Mireia Espallargues.

Conversations on gender in the nursing context

10 May
Marc Fortes, Núria Rodríguez-Valiente, Mercè Salvat

Like every 12 May, the International Nurses Day is celebrated and to commemorate this date, three colleagues in the profession, Mercè Salvat, Marc Fortes and Nuria Rodríguez got together to talk about the relationship between gender and giving care.

We would like to share our reflections on how socially, the profession has been related to vocation, altruism, submissiveness and invisibility…, in short, to the social stereotypes of the female gender.

Questions arose during this conversation such as why the term caregiving is associated with women in our society, why this care does not have nor has had social recognition when opinion is favourable in the processes of health-illness, how the men who have chosen this profession experience it and finally, how it would be possible to “deconstruct” this social and cultural construct.

Let’s take it a step at a time.

Why is the concept of caregiving associated with women in our society?

It is a historical fact that in our patriarchal society, women have been linked to the function of reproduction and taking care of the home. This care should be seen in its widest sense: from the routine chores of housekeeping, to curing and maintaining the health of older people, babies and family members who are ill. At the same time, they have been attributed with a whole series of connotations such as servitude, self-sacrifice, unconditional commitment and in short, of little value. On the other hand, in this context, men have been linked to productivity and the economic sustenance of the family and associated with professionalism and social prestige.

Why does this caregiving not have nor has had social prestige?

This deeply rooted social construct has normalised the idea of caregiving as something feminine. It is taken a step further by establishing stereotypes between that which is feminine, caregiving and the social vocation-intuition-servitude-invisibility. Finally, a symbolic association with essential professions in the care of people is made; this would be the case of nursing. In fact, the stereotyped identification of the profession is replicated socially and the role of the nurse is a professional continuation of home care (Germán, 2004).

In addition, to this collective worldview mentioned previously, we also need to add the sexual-recreational perspective of the profession which unfortunately continues to be present. An example, in the most recent cases, is the flu campaign of 2017 by the Ministry of Health and the TV programme Telepasión – El Musical 2017.

How do the men who have chosen this profession experience it?

This is a question we male nurses have always asked ourselves: What problem is there in carrying out this career? Would anybody have questioned my decision had I decided to be a doctor or pharmacist? This is the first battle to be fought by the men who decide to give care professionally to other people. It is not a battle against themselves but rather against established social prejudices. We will attempt to briefly summarise some of these prejudices:

– “To be able to care for someone, a special sensitivity is needed which only women have.” It appears that men are strong, do not waste time on feelings and of course never cry. Luckily, many of us have shown that professional care requires a set of skills which in the first place can be trained and which secondly do not depend on gender whatsoever, or, as Joan Tronto, the political scientist puts it: “Giving care is not more natural for women; they do it as a privilege for men.

– As we mentioned earlier, the social construct says that “men are the economic pillar of the family”. Nowadays, the average salary of a male nurse might not be enough to sustain a family. In our present day society we need to consider shared responsibility in family management.

– “Men that choose a profession of this type are not very masculine”; the social construct means that some men do not go into these professions because, from a social viewpoint, it is thought that their masculinity might be questioned and consequently, the superiority of gender too. What is more, this idea leads to the attribution of a sexual orientation because of belonging to this collective.

How can this social and cultural construct be deconstructed?

The “deconstruction” of this social construct should lead us towards the revolution of equating caregiving with healing from a human perspective and not from a gender perspective. To be able to give care, it is without doubt necessary to have a predisposition towards solidarity, an emotional commitment and flexibility but these grand values belong to humanity and not to any gender or profession. The perspective of gender is in itself enriching and should bestow on men and women the condition of equality when carrying out their chosen professions regardless of their gender.

In order to “deconstruct” the stereotype of gender in our patriarchal society, we should learn that giving care is a skill that people have and that it has nothing to do with the dichotomy of gender (Barragán, 2009). A feminine or masculine view regardless of sex is necessary in order to look at our profession historically and in terms of the future (Chamizo, 2004) and what is more, we feel the need to add that it is necessary in order to deal with the present and future of society.

In this respect, our proposals are a step towards the definition of a common strategic line proposed by professional colleges of health, where the democratic values which are imbued in taking care and in giving care are promoted.

Post written by Núria Rodríguez-Valiente, Marc Fortes and Mercè Salvat.

Elderly person with stroke: integrated care from the acute phase to the return home

9 Dec
marco-inzitari
Marco Inzitari

Stroke has a high incidence, a growing prevalence and is the pathology with the second highest impact in the world in terms of disability among adults. Despite important advances in acute stroke management, which have led to a progressive decrease in acute stroke deaths, in terms of residual disability, stroke continues to have an extremely high impact on survivors, their families, their caregivers and on society in general.

Evidence shows that the approach to patients throughout the process of care in stroke, from the acute phase to the rehabilitation phase, needs to be multidisciplinary since patients have multiple health care and social needs which require a strong coordination between the different levels of healthcare. However, the tendency is still to organise conferences and congresses focused on only one speciality or level of healthcare.

On the other hand, and in self-criticism, even though stroke is one of the main reasons for using intermediate or long-term healthcare services, this sector almost never takes part in the decision making process of stroke care organisation. Neither does it do much research in stroke and in general, tends to put little thought into improving knowledge in treatments or in innovating the organisation of services compared to, for example, other conditions such as thighbone fractures.

This is why the Parc Sanitari Pere Virgili organised a monothematic symposium on 27 October, two days before the World Stroke Day. It focused on the treatment and management of stroke in elderly people from a different perspective: we traced the trajectory from the “needle” of the thrombolysis in the acute phase, passing through rehabilitative care and “reablement” in the post-acute phase, to the transition back to home life, describing the care given to patients especially, but not forgetting the attention caregivers need.

jornada-ictus-pere-virgili

The presentations reflected and reinforced the need for a multidisciplinary approach in all phases of stroke. As an added value, in all cases the speakers not only combined recommendations derived from literature with their own practical healthcare experience but also provided data from their own research or innovation projects, in many cases with data published recently.

Among the speakers there was a varied representation from very different disciplines which included neurologists, geriatricians, physiotherapists, occupational therapists, speech therapists, social workers, a health economist and the representative of the stroke patients association who chaired a roundtable.

Some of the items that were highlighted most strongly during the symposium were:

  1. The large amount of increasingly more accurate data available on all phases of stroke management. In Catalonia, this data is being provided by the Results Centre, which encourages transparency and allows for benchmarking thereby facilitating a reduction in variability and the sharing of best practices.
  2. Despite improvements in the treatment of acute stroke patients using mechanical thrombectomy together with systemic thrombolysis, 40% of patients are left with a considerable disability as a consequence of stroke. This “glass half-full” should therefore encourage more to be done in terms of acute stroke management, and also in post-acute care which is still vital.
  3. In acute care, age should not be a discriminating factor. This is in line with the concept that chronological age does not correspond necessarily to biological age and that two elderly people of the same age can have a totally different “functional potential” (a concept which in practice in the field of geriatrics is understood as meaning more or less “frail”).
  4. Advances have not only been made in acute care but also in the field of primary and secondary preventive care. Accordingly, the development, the approval of and the use of NOACs (new oral anticoagulants) have been a determining factor since they offer an alternative for those patients where traditional anticoagulants are not a therapeutic option.
  5. The rehabilitation prognosis is multifactorial. A recent proposal stemming from a multi-centre Catalan study led by our hospital and published recently, is based on a simple algorithm which incorporates the social factor (presence of the caregiver) together with the severity of the stroke (using the NIHSS score), functional status (according to the Barthel index) and cognitive function (a result of the Rancho Los Amigos scale). This allows patients to be classified in three levels of rehabilitation complexity, but who might evolve differently, with different needs for intervention, both in the rehabilitation process and regarding their return home.
  6. Integrated interventions in geriatric rehabilitation can be home-based for certain patients as an alternative to a hospital admission. This model, deeply rooted in England and which has proven to be beneficial, is producing good results in our context in different pathologies including stroke. Innovative formulas such as “Comprehensive Home-based Hospitalisation” have, in our context, come about from the alliance between home-based geriatric care teams (doctor, nurse and social worker) and those of home-based rehabilitation (rehabilitation doctor, physiotherapist, occupational therapist and speech therapist).
  7. In terms of physiotherapy, treatments should be more standardised and their efficacy demonstrated. During the symposium, interesting evidence was presented on the control of the trunk and its importance throughout the rehabilitation process in stroke.
  8. Dysphagia is a very prevalent risk condition in patients who have suffered a stroke. Different proposals of scales for assessment at the bedside were shown which can be applied by nurses, reserving the speech therapist’s intervention for the most complex cases which require a more specialised assessment.
  9. In rehabilitation, the support from the ICT (“telerehabilitation” which patients can receive following the instructions and programme configuration of the physiotherapist) allows treatments to be extended in time and intensity along with face-to-face treatment.
  10. Working with caregivers is important. Apart from guiding them within the system, the availability of support groups for exchanging personal experiences, for a social worker, for example, could have an impact on the adaptation of the caregiver to the new situation. To this effect, an innovative experience was developed in our centre with a high degree of acceptance by patients and their families.
  11. Continuity in the recovery process is key and the integration of health and social services guarantees an added value. The pilot “Return Programme” in the city of Barcelona, the result of the alliance between the Catalan Health Service and the City Council of Barcelona was presented. It allows for the direct activation of social services, from acute care and long-term care hospitals so that patients can receive the necessary aid when they return home and thus avoid unnecessary and dangerous delays.

In summary, much progress has been made in the treatment of stroke, especially in the acute phase, but innovation is also being carried out in the successive phases and the symposium showcased different experiences which have been implemented in our context. Drawing conclusions from the symposium, the take home messages are that a comprehensive view of the entire process is key, as well as an integrated and coordinated approach between the different levels of healthcare and social services. On the other hand, more research needs to be carried out especially in the post-acute and chronic phases resulting from the disease and this poses a challenge because of the difficulty in designing and implementing complex interventions where designs such as standard clinical trials are not the solution.

Post written by Marco Inzitari (@marcoinzi) and Laura Mónica Pérez, Parc Sanitari Pere Virgili, Barcelona.